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

We decided that the Plan does not have to approve additional payment for the contact lenses provided on November 12, 2019.You asked the Plan to approve additional payment for the contact lenses. You say that you were told the contact lenses would be covered.The Plan denied your request. The Plan says that your request exceeds the benefit limit.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 a $100 allowance for contact lenses per year.We looked at the file and Medicare rules. The file shows that the plan has approved the maximum yearly benefit of $100 for the requested services. There is no provision in the contract which would require the plan to approve more than this amount.Therefore, we decided that the Plan does not have to approve additional payment for the contact lenses provided on November 12, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement power wheelchair.
You asked the Plan to pre-approve a replacement power wheelchair. You say that you feel your power wheelchair needs replacement. The Plan denied your request. The Plan says a technician assessed your power wheelchair and says it does not need replacement and meets your needs.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The documentation submitted does not show that your power wheelchair is irreparably worn, irreparably damaged, or that you have had a change in medical condition to warrant the replacement power wheelchair at issue. Based on the records provided, there is no indication that a replacement power wheelchair meets Medicare coverage criteria. Therefore, we decided that the Plan does not have to pre-approve a replacement power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Somnomed oral appliance (E0486).You asked the Plan to pre-approve the oral appliance. You say that your current oral appliance is causing a lot of pain and you have obstructive sleep apnea and really need another appliance.The Plan denied your request. The Plan says you were approved for an oral appliance and received it January 2, 2020 and there is no indication that the appliance is not working and does not include a medical reason for a second oral appliance.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have a Somnomed oral appliance (E0486). The Somnomed oral appliance (E0486) serves the same purpose as the oral appliance.Therefore, we decided that the Plan does not have to pre-approve Somnomed oral appliance (E0486).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the replacement of back-up Bipap machine. You asked the Plan to pre-approve the replacement of back-up Bipap machine. You say that you have 2 Bipap machines and your older machine is not working properly. You have an order from your physician for a replacement machine and you feel the plan should provide it to you.The Plan denied your request. The Plan says you currently have a fully functional Bipap machine that was delivered to you November 2017. Back-up or duplicate equipment is not a covered benefit my Medicare.The Plan must follow Medicare rules. The rules say Medicare covers DMEonly when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have a Bipap received in 2017. The Bipap received in 2017 serves the same purpose as the back-up Bipap machine.Therefore, we decided that the Plan does not have to pre-approve the replacement of back-up Bipap machine
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.You asked the Plan to pre-approve the SNF admission.You say that you received many recommendations from friends, family and medical professionals that this facilitycan provide the care your father needs with the resources available and the emotional support the other facilities may not have. The Plan denied your request. The Plan says there is no documentation of an urgent or emergent need for the enrollee to receive skilled nursing care with at an out-of-network SNF. There are network providers available that can provide adequate skilled care the enrollee needs.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested SNFin this case is not a networkprovider with the Plan. The Plan has network providers available who can provide the SNF services at issue in this appeal. We found no exception that would require the Plan to pre-approve the requested SNF services. Therefore, we decided that the Plan does not have to pre-approve a SNFadmission
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom compression stockings identified with codes S8423, S8426.
You asked the Plan to pre-approve the compression stockings. You say that you require the custom stockings for treatment of lymphedema. The Plan denied your request. The Plan says custom compression garments are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code S8423, S8426 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve custom compression stockings identified with codes S8423, S8426.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on March 11, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on March 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on February 28, 2019.
You asked the Plan to pay for lab tests. You say that you are appealing with additional medical documentation. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent laboratory bills for services, the plan where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The record shows that the sample for this testing was taken in an office setting, therefore the Place of Service (POS) code 81 - indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on February 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement CPAP device with humidifier and supplies.You asked the Plan to pre-approve a replacement CPAP device with humidifier and supplies. You say that the enrollee needs a replacement CPAP device.The Plan denied your request. The Plan says no information could be obtained from the enrollee's physician regarding the current CPAP device or objective confirmation of regular use. The Plan must follow Medicare rules. Therecord does not contain documentation that the enrollee's symptoms are improved or adherence of using the current CPAP device. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a replacement CPAP device have not been met.Therefore, we decided that the Plan does not have to pre-approve a replacement CPAP device with humidifier and supplies.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment forthe colonoscopy provided on August 26, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that this was a routine screening colonoscopy. You say that the incorrect code was billed.The Plan denied your request. The Plan says that the copayment applied correctly.The Plan must follow Medicare rules. Medicare covers 1 screening colonoscopy every 2 years or 1 barium enema every 2 years for people with high risk of colon cancer. An individual with a person history of polyps meets the definition of "person with high risk of colon cancer" under Medicare rules. There is no evidence that this colonoscopy was ordered for diagnostic purposes or that a biopsy was performed during this colonoscopy. The diagnosis codes billedsupports that a colorectal cancer screening was performed. A person with a personal history of polyps is considered to be at high risk of colon cancer. People at a high risk of colon cancer are eligible for screening colonoscopies under Medicare rules and these screening colonoscopies are covered at a greater frequency for those at high risk. No evidence has been submitted to show that your screening colonoscopy benefit was exhausted on this date of service. Based on the documentation submitted by the health plan, we find that you received a screening colonoscopy. Medicare rules say that, if a preventive service is covered with $0 cost-sharing under Original Medicare, the health plan cannot impose cost-sharing for the service when it is provided by in-network providers. Priority Health must follow this rule. The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that there is no coinsurance, copayment or deductible for a Medicare-covered colorectal cancer screening exam.The Plan says you must pay a $340 copayment for the colonoscopy. Based on the Plan contract, however, you cannot be asked to pay more than $0 for the colonoscopy.Therefore, we decided that the Plan has to waive the copayment forthe colonoscopy provided on August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upright walker to be provided.You asked the Plan to pre-approve the upright walker. The Plan denied your request. The Plan says non-network providers are not covered when participating providers are available. The benefits are available with a participating DME vendor.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the itemat issue in this appeal. We found no exception that would require the Plan to pre-approve this item.Therefore, we decided that the Plan does not have to pre-approve an upright walker to be provided.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study (95810).You asked the Plan to pre-approvea sleep study. You say that this is medically necessary.The Plan denied your request. The Plan says a repeat sleep study is not necessary because there's no evidence that the enrollee may no longer need continuous positive airway pressure (CPAP) treatment.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 a sleep study. Our reviewer says that the requested sleep study is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has had Obstructive Sleep Apnea (OSA) for many years, and does well on CPAP. The sleep study in 2015 was done because the patient had lost 80 pounds, and it still showed severe OSA. Thus it seems very unlikely that the OSA will have resolved with only a 20 lb weight loss, which is less than the 10% weight change considered significant enough to warrant a new study.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 sleep study have not been met.Therefore, we decided that the Plan does not have to pre-approvea sleep study (95810).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751) and a prefabricated post and core in addition to a crown (D2954) for tooth # 14.
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says crowns are not covered services.
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, crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown (D2751) and a prefabricated post and core in addition to a crown (D2954) for tooth # 14.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forwound debridement provided from September 6, 2019 to January 15, 2020.You asked the Plan to waive the copayments forwound debridement. You say that you disagree with the surgery charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers provided in 2019 and a $250 copayment when provided in 2020.You received wound debridement from September 6, 2019 to January 15, 20202 for a total of 6 visits. Therefore, you are responsible to pay the total amount of $1,081.07 which is less than the total copayment amount. You have been asked to pay the total amount of $1,081.07 for wound debridement. Wound debridement 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 copayments forwound debridement provided from September 6, 2019 to January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital stay provided on November 7, 2019.
You asked the Plan to waive the copayment for an outpatient hospital stay. You say that you should not be charged extra for a follow-up visit. 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 $325 copayment for outpatient hospital services. You had an outpatient hospital stay on November 7, 2019. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the allowed amount of $87.04, which is less than the $325 copayment. You have been asked to pay $87.04 for an outpatient hospital stay. An outpatient hospital stay 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 for an outpatient hospital stay provided on November 7, 2019.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to reduce the copayments for the radiation treatments. We decided that the Plan does not have to waive the copayments for the radiation treatments. You asked the Plan to reduce the copayments for the radiation treatments. You say that you were unaware that radiation was covered as outpatient hospital services. You say you were told the radiation would be covered as a specialist office visits.The Plan says that you have been charged the correct cost sharing amount.We decided that the Plan has to reduce the copayments for the radiation treatments. The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The record shows that the Plan billed for radiation therapy services. The Plan says that you must pay a total of $938.06 for radiation therapy. Based on the plan contract, however, you cannot be asked to pay more than a $25 copayment for radiation therapy on each date of service. ($25 x 19 dates of service = $475). Therefore, we decided that the Plan has to reduce the total copayment amount for the radiation treatments from $938.06 to a total copayment amount of $475. Therefore, we decided that the Plan has to reduce the copayments forthe radiation treatments. We also decided that the Plandoes not have to waive the copayments forthe radiation treatments.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 $25 copayment for the radiation treatments.Therefore, we decided that the Plan does not have to waivethe copayments forthe radiation treatments.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 3, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for services obtained from a primary care provider or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a primary care provider's office. The enrollee has been asked to pay asked to pay a $10 copayment for the office visit. The office visit falls within the services obtained from a primary care provider or under certain circumstances, treatment by a nurse "Physician/Practitioner services, including doctor's office visits" 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 office visit provided on October 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November 17, 2019.You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because you were taken to another county.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 $300 copayment for ambulance services. You have been asked to pay a $300 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on November 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cataract surgery rendered on August 27,
2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 66984 is not supported.
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 66984 is extracapsular cataract removal with insertion of
intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or
phacoemulsification).
We find that CPT code 66984 is not supported in the medical record. Specifically, the documentation does not
include a procedure note to support that extracapsular cataract removal was performed. Based on this
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we
decided that the Plan does not have to pay for the cataract surgery rendered to the enrollee on August 27,
2019.