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

We decided that the Plan does not have to pay for the refraction testing provided on September 30, 2020.
You asked the Plan to pay for the refraction testing. You say that you do not understand why this was denied as
you have never gotten a denial for these services in the past. The Plan denied your request. The Plan says the
refraction was correctly denied as noncovered.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and
eyewear. The contract with the Plan says that routine vision services are covered when received by a plan
provider.
You were seen for a medical eye exam related to prior cataract surgery. Although refraction testing may have
been appropriate, Medicare does not provide coverage for this. Your plan only covers this when done as part of
a routine eye exam by an plan provider. Therefore, we decided that the Plan does not have to pay for the
refraction testing provided on September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine vision care provided on October 6, 2020.
You asked the Plan to pay for the services provided. You say that you purchased vision coverage with the
understanding the services would be covered. The Plan denied your request. The Plan says the provider is not
participating.
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. The services were not provided by a plan provider. Based on
this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that
the Plan does not have to pay for the routine vision care provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider on July 20, 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 to the enrollee by an out-of-network provider on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on July 8, 2020.
You asked the Plan to pay for the services provided. You say that the enrollee relied on the facility staff to
ensure he would have an eye exam. The Plan denied your request. The Plan says the enrollee has no out-ofnetwork
plan benefits for the refraction.
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. The documentation does not show the routine vision services were
provided by a network optical provider. Based on this information, we decided that the Plan's rules for
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the vision services
provided on July 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for chemotherapy services, laboratory test and body injector application provided on December 21, 2020.
You asked the Plan to waive the cost for the chemotherapy services, laboratory test and body injector. You say
that this amount should be covered in full by insurance. The Plan denied your request. The Plan says the cost
share 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 each Medicare-covered Part B drug, a $10 copayment for Medicare-covered lab services and a
$325 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 total of $1,905.32 for the chemotherapy services, laboratory test and body
injector.
Date of Service Allowed Amount Standard Cost Member Liability
Chemotherapy Infusions $831.04 $325 $166.20
Injections $7,926.06 20% $1,585.21
Laboratory Test $211.12 $10 $10
Body Injector Application $143.91 $325 $143.91
TOTAL: 1,905.32
The chemotherapy injections fall within the "Medicare Part B Prescription Drugs" benefit category. The
laboratory test falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit
category. The chemotherapy infusions and body injector application fall within the "Outpatient Surgery and
Other Medical 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 cost for chemotherapy services, laboratory test and body injector
application provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear you received on December 3, 2020.
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says this is an out-ofnetwork
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 a $150 coverage limit when provider by an in-network
provider.
We looked at the file and the Plan's rules. The requested eyewear was provided by an out-of-network provider
with your vision plan. The Plan does not cover out-of-network routine eyewear. Therefore, we decided that the
Plan does not have to pay for the eyewear you received on December 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission provided from January 15, 2021, to February 13, 2021.
You asked the Plan to pay for the SNF admission. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive any daily skilled nursing or rehabilitation services on the dates of service in this case.
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 SNF admission 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 skilled nursing facility (SNF) admission provided from January 15, 2021, to February 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on November 18, 2020.
You asked the Plan to pay for the vision services. You say that you went in for a routine examination that has
always been covered in the past. The Plan denied your request. The Plan says services provided by an out-ofnetwork
vision provider is not covered under your Plan.
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers
these services when provided by the Plan's vision provider.
We looked at the file and the Plan's rules. The file shows that the vision services were provided by an out-ofnetwork
vision 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 for vision services
provided November 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a participating provider on December 29, 2020, to January 27, 2021.

You asked the Plan to waive the copayment for a skilled nursing stay. You say that you should not be responsible for anything after day 21. The Plan denied your request. The Plan says the correct copayment has 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). Your contract with the Plan clearly says that you must pay a $0 copayment per day for days 1-20. There is a $178 copayment per day for days 21-100 for skilled nursing facility (SNF) care/in-network.

You have been asked to pay a $0 copayment per day for days 1-20 (December 29, 2020 - January 17, 2021). There is a $178 copayment per day for days 21-31 (January 18, 2021 - January 17, 2021) for a skilled nursing stay. The total amount you are being asked to pay is $1,780 ($178 x 10 days = $1,780). A skilled nursing stay falls within the skilled nursing facility (SNF) care/in-network 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 skilled nursing stay provided by a participating provider on December 29, 2020, to January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on May 21, 2020.
You asked the Plan to reimburse you for the eyeglasses. You say that Covid restrictions had closed all person to person contact and the eyeglasses purchased on September 2019 were scratched and needed replacing. You say that this provider had your prescription and the frames were in stock. You say it was the safest choice at the time. The Plan denied your request. The Plan says there is no coverage for out-of-network optical services.
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. The file shows the requested provider in this case is not a network vision provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on May 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myopro Motion G Orthotic device.

You asked the Plan to pre-approve Myopro Motion G Orthotic device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested device is 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 Myopro Motion G Orthotic device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found despite undergoing occupational therapy targeted at restoring his native strength and range of motion, the enrollee's right arm remains unable to functionally bear weight. The enrollee therefore continues to be largely incapable of bimanual activities of daily living and instrumental activities of daily living, requiring routine help at home from paid staff. There is insufficient literature in the peer reviewed publications to assess safety, efficacy, long term outcomes or enrollee management associated with the use of the MyoPro Orthosis for upper extremity paralysis/paresis from conditions such as multiple sclerosis or other neuromuscular/neurological disease or injury.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Myopro Motion G Orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve Myopro Motion G Orthotic device.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99347) provided on June 6, 2020.

You asked the Plan to pay for the home visit. You say that the in-home medical services were necessary. The Plan denied your request. The Plan says the provided records do not support that a physician or non-physician practitioner (physician assistant or nurse practitioner) were physically present in the enrollee's home. The Plan also says the submitted code does not appropriately reflect the services provided by a registered nurse.

The Plan must follow Medicare rules. Medicare rules say that a home visit cannot be billed by a physician unless the physician was actually present in the beneficiary's home.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99347) provided on June 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and
interpretation with field of view of both jaws; with or without cranium (D0367) received Mach 29, 2021.
You asked the Plan to pay for the cone beam CT capture. You say that the requested service is necessary and
was not performed for cosmetic purposes. The Plan denied your request. The Plan says the requested service is
not covered under your supplemental benefit.
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. Therefore, we decided that the Plan does not have to pay for the cone
beam computed tomography (CT) capture and interpretation with field of view of both jaws; with or without
cranium (D0367) received Mach 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the rehabilitation and drug services rendered on September 14, 2020 and September 21, 2020.

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 codes 97112, J3411, J3415, and J3490 are 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 97112 is therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities. The definition of code J3411 is injection, thiamine hcl, 100 mg. The definition of code J3415 is injection, pyridoxine hcl, 100 mg. The definition of code J3490 is unclassified drugs.

We find that CPT codes 97112, J3411, J3415, and J3490 are not supported in the medical record. Specifically, there is no documentation of length of time for the services to support code 97112. There is no documentation of administration of thiamine as an ingredient in a vitamin blend to support code J3411. There is no documentation of pyridoxine as an ingredient of a vitamin blend to support code J3415. The records show that a nutria-pharmaceutical blend was administered, therefore; separate billing of code J3490 is not supported. 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 rehabilitation and drug services rendered on September 14, 2020 and September 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
You asked the Plan to pre-approve a Freestyle Libre. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered benefit in this case.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the face mask interface (A7031), the water chamber for a humidifier (A7046), the positive airway pressure headgear (A7035), and the positive airway pressure tubing (A7037) provided on January 14, 2021 and March 2, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the items provided.
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 20% coinsurance for durable medical equipment and related supplies.
You have been asked to pay $36.86 (Plan allowed amount of $184.35 x 20% coinsurance) for the durable medical supplies provided. 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 face mask interface (A7031), the water chamber for a humidifier (A7046), the positive airway pressure headgear (A7035), and the positive airway pressure tubing (A7037) provided on January 14, 2021 and March 2, 2021.
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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for altered mental status and a urinary tract infection. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation
program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on March 1, 2021.

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 the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on March 1, 2021.