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

We decided that the Plan has to pay for vision services provided on February 9, 2019.
You asked the Plan to pay for the vision services. You say that you did not realize you had vision coverage.
The Plan denied your request. The Plan says that the claim was not submitted within a six (6) month timeframe.
The rules say that claims must be filed no later than the close of the period ending 1 calendar year after the date
of service. 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 $200 of the allowed amount every year for contact lenses and
eyeglasses from in-network or out-of-network providers.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of these services have been met. Specifically, the Plan is denying payment based on the claim not
being submitted within a 6 month time-frame. Medicare considers claims to be filed timely when submitted
within 12 months of the date of service. Your claim was filed in a 10 month time-frame. The Plan is applying
timely filing limits that are more restrictive than Medicare timely filing limits. The record does not show that
you exhausted your supplemental vision benefit for 2019. Therefore, we decided that the Plan must reimburse
up to $200 of the allowed amounts, less applicable cost-sharing.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on November 25, 2019.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you disagree with the charges because you were not told that you would owe more than the $100 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 $200 copayment for outpatient surgery services provided in an outpatient hospital facility. The medical records show that you received a diagnostic colonoscopy on November 25, 2019. Therefore, you are responsible to pay the $200 copayment. You have been asked to pay a $200 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy 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 for a diagnostic colonoscopy provided on November 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lens (V2521) purchased on December 2, 2019.
You asked the Plan to pay for the contact lens. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.
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 contact lens have not been met. You exhausted your $150 maximum benefit allowance,
because the Plan paid $130 for services on June 19, 2019 and $20 for date of service December 2, 2019. Your
EOC states, if the eyewear you purchase costs more than $150, you pay the difference. Therefore, we decided
that the Plan does not have to pay for contact lens (V2521) purchased on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dialysis services provided on October 1, 2019 to October 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit when provided by an OON provider.
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 the dialysis services provided on October 1, 2019 to October 31, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services provided to the enrollee from December 27, 2019 to December 31, 2019 and billed under code S9328.
You asked the Plan to pay for code S9328. You say that this claim should be paid. The Plan denied your request. The Plan says code S9328 has an invalid status code indicator for Medicare billing.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the code billed has a status code indicator of "I" which that does not allow payment on Medicare claims. Therefore, we decided that the Plan does not have to pay for home infusion services provided to the enrollee from December 27, 2019 to December 31, 2019 and billed under code S9328.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says there is a lack of medical necessity.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 enrollee's medical conditions appear stable. There are no complex wound care
needs. There are no unaddressed medical issues. He does not require medical oversight of his condition at an
acute hospital level of care. He is ambulating community level distances and is performing essential activities
of daily living without hands-on assistance and does not require an intensive rehabilitation therapy program.
There is no reason to think that an intensive rehabilitation therapy program would significantly impact the
enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can
be appropriately provided through home-based and outpatient 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the immune globulin injection and intravenous infusions provided on December 19, 2019.
You asked the Plan to waive the coinsurance for the immune globulin injection and intravenous infusions. You say that you have always paid a specialist copayment. You say that you cannot afford the cost. The Plan denied your request. The Plan says the coinsurance applied 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 20% coinsurance for Medicare Part B covered drugs and chemotherapy drugs. You have been asked to pay $281.60, which is less than the standard 20% coinsurance because you met your maximum out-of-pocket. The immune globulin injection and intravenous infusions fall within the "Medicare Part B prescription drugs" 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 coinsurance for the immune globulin injection and intravenous infusions provided on December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing exam provided on November 19, 2019.You asked the Plan to pay for the hearing exam. You say that you needed this exam to verify what type of hearing aids you require.The Plan denied your request. The Plan says that this is not covered by the Plan.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 says that you MUST use an in network provider for the hearing benefit.We looked at the file and the Plan's rules. The file indicates you did not use an in network provider. Based on this information, we decided that the Plan's rules for coverage of the hearing exam have not been met.Therefore, we decided that the Plan does not have to pay for the hearing exam provided on November 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood sugar testing rendered on December 10, 2019.
You asked the Plan to pay for these services. You say that you have diabetes and had to have your A1C levels
tested before surgery. The Plan denied your request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that glycated hemoglobin testing is covered for
management and control of diabetes.
We looked at the file and Medicare rules. The file shows that the provider billed the claim for these services
with a diagnosis of palmar fascial fibromatosis, which is not a condition for which this testing is covered.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Please note that the Plan has confirmed that you are being held harmless for these services. Therefore, we
decided that the Plan does not have to pay for the blood sugar testing rendered on December 10, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for subsequent hospital care (99233) provided on January 27, 2020 through January 29, 2020.
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration because these services were rendered by providers with different specialties. The Plan denied your request. The Plan says that this service was bundled as part of those global surgical fee because it was reported within 90 days of the major surgical procedure.
The Plan must follow Medicare rules. Medicare rules say that services that are not considered part of the global surgery package include services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have been met. Specifically, the record indicates that these services were rendered by separate providers. There is no indication that these physicians agreed upon a transfer of care. Therefore, we decided that the Plan has to pay for subsequent hospital care (99233) provided on January 27, 2020 through January 29, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Topiramate, 200 mg, tablet.You asked the Plan to pre-approve Topiramate. You say that the enrollee has taken the requested drug in the past. You say that it has proven successful in the past. You also say that the requested drug is necessary to treat the enrollee's trigimal neuralgia flare us.The Plan denied your request. The Plan says you have a medical only policy, not a Prescription Drug Plan. The Plan also says drug coverage is limited to Medicare Part B covered drugs.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 pre-approve the Topiramate, 200 mg, tablet.Benefits for Topiramate 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 20, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
Review of the file shows that medical records were not provided in order to determine the clinical utility of the
testing. The documentation does not support that the laboratory testing at issue in this appeal was not requested
solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we
decided that the Plan does not have to pay for the laboratory services provided on November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on December 5, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on December 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on October 16, 2019.
You asked the Plan to waive the copayment for the arthrocentesis. You say that this was scheduled as a specialist office visit. You say you should not be charged the additional facility charge since you were not made aware that a facility charge may apply to a specialist visit. 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 $300 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $300 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows you were billed separately by the outpatient hospital for the arthrocentesis.
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 arthrocentesis provided on October 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation feature or upgraded electronics.
You asked the Plan to pre-approve the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), Expandable controller (E2377), or a power seat elevation feature (E2300). You say that you need all these features for your power wheelchair. The Plan denied your request. The Plan says although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. The power options come with their own switches. The power seat elevation feature is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. The seat elevation feature does not serve a purpose that is primarily medical in nature. Documentation shows that the enrollee has a functional range of motion and 3/5 strength in the bilateral upper limbs. Upper limb strength and range of motion are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options. Based on this information, we decided that Medicare rules for coverage of the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), Expandable controller (E2377) and a power seat elevation feature (E2300) have not been met. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation feature or upgraded electronics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 40mg Pantoprazole tablets.
You asked the Plan to pre-approve the Pantoprazole. You say that you would like reconsideration because the member's symptoms have been successfully treated with this medication. The Plan denied your request. The Plan says this medication does not fall under Medicare Part B coverage.
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 pre-approve 40mg Pantoprazole tablets.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living services provided on October 7, 2019 by an out of network (OON) provider.You asked the Plan to pay for assisted living services. You say that it is the facility's responsibility to obtained prior authorization.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring assisted facility is not in-network.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 assisted living services provided on October 7, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that there was no reason to transport you as all danger had passed, and it would have been expensive to go to the hospital.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 5, 2019. The ambulance benefit is a transportation benefit. When there is no transport,neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 3.
You asked the Plan to pre-approve the core build up. You say that the provider took x-rays. You say that the enrollee would benefit from a crown on tooth # 3 in order to prevent fractures. The Plan denied your request. The Plan says core build up 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, the requested core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 3.