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

We decided that the Plan does not have to pay for ophthalmology services (92012) vision field test (92083) scanning computerized ophthalmic diagnostic imaging (92133) provided on July 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for ophthalmological services. You say that since your company has an exclusive contract with the facility, your doctors are the only providers who will treat the patients for optometry care. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 ophthalmology services (92012) vision field test (92083) scanning computerized ophthalmic diagnostic imaging (92133) provided on July 21, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on July 31, 2020.
You asked the Plan to waive the coinsurance for DME. You say that you got the same supplies for cheaper
somewhere else and feel that the charges are too high. 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 20%
coinsurance for DME and related supplies.
You received DME on July 31, 2020. The allowed amount is $723.35 and 20% of that is $144.67.
You have been asked to pay the total coinsurance amount of $144.67 for DME. DME falls within the DME and
related supplies 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 DME provided on July
31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for outpatient hospital and physician services provided on August 6, 2020.

You asked the Plan to waive these copayments. You say that you do not believe these copayments are correct. The Plan denied your request. The Plan says these copayments were charged based on the services provided and the Plan contract agreement. 
The Plan states that based on the claims submitted; your provider utilizes hospital-based billing. This means that each visit results in two billings; a professional claim for the doctor that was seen, and a facility claim for the use of the space. When services are billed on a professional claim, the professional benefits apply. When services are billed on a facility claim, the out-patient benefits apply.

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 cost share for facility and physician services. 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 charged for outpatient hospital and physician services provided on August 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Stool Profile panel testing provided on March 23, 2020.
You asked the Plan to pay for genetic testing. You say that these codes are covered by Medicare. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing has not been reviewed and approved for coverage for this date of service.
The Plan must follow Medicare rules. Medicare rules say that Medicare only covers molecular diagnostic tests that have been approved through the MolDX process. We looked at the file and Medicare rules. This testing was not approved for coverage for this date of service. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for Comprehensive Stool Profile panel testing provided on March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $10 copayment charged for a physician visit provided on June 24, 2020.
You asked the Plan to waive this copayment. You say that this copayment is not correct as this was an annual wellness visit. The Plan denied your request. The Plan says the copayment was applied correctly because your physician billed a separate claim for services beyond an annual wellness visit.
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 $10 copayment for physician services. The annual wellness visit covers the limited services listed above. The annual wellness visit does not cover diagnostic services or physician services provided beyond those described. Providers may bill for additional services resulting from the wellness visit. 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 $10 copayment charged for a physician visit provided on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213), slings (A4565), triamcinolone
acetonide injection (J3301) and aspiration and/or injection of large joint or joint capsule (20610) provided on
April 10, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for office visit, injection, sling and surgery. You say that the services should be
reimbursable as in-network claims. The Plan denied your request. The Plan says prior authorization must be
obtained for non-emergent services rendered by an out-of-network 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 office visit (99213), slings (A4565),
triamcinolone acetonide injection (J3301) and aspiration and/or injection of large joint or joint capsule (20610)
provided on April 10, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. Medicare rules say that BRCA testing is covered for beneficiaries with a
personal history of breast or ovarian cancer.
We looked at the file and Medicare rules. The file shows that you do not have a personal history of breast or
ovarian cancer. 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 pre-approve BRCA genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve astigmatism correcting function of intraocular lens (CPT Code V2787).
You asked the Plan to pre-approve the lens. You say that you do not understand why the Plan would not cover this type of lens when the Plan will cover all others. The Plan denied your request. The Plan says Medicare criteria for vision services do not cover the special lens for any reason. The Plan states neither Medicare nor your health plan covers the special lens. The Plan states a regular lens is the only type of lens that is covered.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. Medicare guidance says astigmatism correcting intraocular lens is not covered by Medicare. A presbyopia correcting intraocular lens insertion is covered by Medicare after cataract surgery. You would have to pay extra for insertion of a lens that corrects for astigmatism too. Therefore, we decided that the Plan does not have to pre-approve astigmatism correcting function of intraocular lens (CPT Code V2787).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinjection(s), diagnostic or therapeuticagent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral (CPT Codes: 64494, 64493, 64495).You asked the Plan to pre-approvethe services. You say that this is an urgent request for the member to avoid further suffering.The Plan denied your request. The Plan says they do not have notes of recent ongoing conservative treatment. The Plan states this request is not supported due to a lack of exam findings and the presence of radicular pain.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is very poor documentation of the history and physical examination. It does NOT specify which levels were blocked, duration and degree of relief obtained and does not specify which levels are to be blocked. There is no role for a series of medial branch blocks. The request is deemed not medically reasonable or necessary due to the poor documentation.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approveinjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral (CPT Codes: 64494, 64493, 64495).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an x-ray and radiology services provided by
a participating provider on July 6, 2020.
You asked the Plan to waive the deductible for an x-ray and radiology services. You say that you think you are
being overcharged. The Plan denied your request. The Plan says the correct deductible amount has been
applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $150 deductible for outpatient diagnostic tests/in-network.
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient
diagnostic tests/in-network. The Plan has followed Medicare rules by clearly disclosing in the contract that
there is a $150 deductible for outpatient diagnostic tests/in-network. This cost sharing is a contractual
obligation that had not been met at the time an x-ray and radiology services was received on July 6, 2020. The
total amount you are being asked to pay is $121.93. Therefore, we decided that the Plan does not have to waive
the deductible for an x-ray and radiology services provided by a participating provider on July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve
branches including imaging guidance, when performed (CPT Code 64624).
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your
request. The Plan says medical studies have not proven that the service(s) or procedure(s) is helpful for
treatment of your health problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this is an experimental/ investigational procedure that is the subject of on-going clinical trials.
You are not enrolled in a clinical trial. Therefore, the request is considered not medically reasonable or
necessary.
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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance,
when performed (CPT Code 64624).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on May 20, 2020.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says
the enrollee must use network (contracted) providers to get medical care and services. The only exceptions are
emergencies, urgently needed services when the network is not available, and cases in which the Plan
authorizes use of out-of-network providers.
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 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 diagnostic radiology services provided on May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore buildup, including any pins when required, tooth #8 (CPT Code D2950).You asked the Plan to pre-approvethe dental services. You say that you need this service because the post is needed for the crown to be put in.The Plan denied your request. 

The Plan says the service is not a covered benefit under the plan.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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pre-approvecore buildup, including any pins when required, tooth #8 (CPT Code D2950)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed with rails and mattress
innerspring.

You asked the Plan to pre-approve semi-electric hospital bed. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says the denial of authorization for these items is correct,
because the enrollee does not meet the Medicare criteria for a semi-electric hospital bed.

The Plan follows Medicare rules. Medicare rules say that semi-electric hospital beds are covered when the
above clinical criteria have 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 semi-electric hospital bed. Our reviewer
says that the enrollee does not meet the Medicare criteria for the requested semi-electric hospital bed with rails
and mattress innerspring. Our physician reviewer found the documentation does not reveal that the enrollee's
condition has failed positioning of the bed in ways not feasible in an ordinary bed, or why positioning of the
bed in other ways is not feasible. The documentation does not support a need for an immediate or frequent
change in body position or special attachments that cannot be fixed to an ordinary bed. The head of the bed
does not need to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic
pulmonary disease, or problems with aspiration. Therefore, the requested semi-electric hospital bed is not
medically necessary for the enrollee. As the hospital bed is not medically necessary, the accompanying rails
and mattress innerspring are also not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of semi-electric hospital bed have not been met. Therefore, we decided that the
Plan does not have to pre-approve a semi-electric hospital bed with rails and mattress innerspring.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sensor for use with interstitial continuous glucose
monitoring coded with A9276 for the enrollee.
You asked the Plan to pre-approve the sensor. You say that this is medically necessary. The Plan denied your
request. The Plan says that there is no reason the enrollee can't use the Freestyle device.
The Plan must follow Medicare rules. Medicare rules say that CGM devices covered by Medicare under the
DME benefit are defined as therapeutic CGMs and code A9276 is used to describe the supplies used with a
non-therapeutic CGM.
We looked at the file and Medicare rules. Based on this information, we decided that you are requesting
supplies for a non-therapeutic CGM. Medicare will only cover therapeutic continuous glucose monitors and
supplies. Therefore, we decided that the Plan does not have to pre-approve a sensor for use with interstitial
continuous glucose monitoring coded with A9276 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tooth brushing instruction (D1330), core build up
(D2950) for tooth # 12, a filling (D2920) for tooth # 12, a nerve treatment (D3320), a periodontal follow up
appointment (D4910), and local anesthesia (D9210).
You asked the Plan to pre-approve the dental services. You say that The Plan denied your request. The Plan
says the requested dental services are not listed as covered.
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 pre-approve tooth
brushing instruction (D1330), core build up (D2950) for tooth # 12, a filling (D2920) for tooth # 12, a nerve
treatment (D3320), a periodontal follow up appointment (D4910), and local anesthesia (D9210).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxychloroquine.
You asked the Plan to pre-approve Hydroxychloroquine. The Plan denied your request. The Plan says this drug
is not covered for your condition by 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 pre-approve Hydroxychloroquine.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health procedures and services (99509) provided February 1, 2020 to May 31, 2020.You asked the Plan to pay forhome health procedures and services. You say that your mother was denied for reimbursement of a bill that you had to pay and you would like to appeal it.The Plan denied your request. The Plan says custodial care is not a covered benefit under Medicare or the Plan. Additionally, medical records were not provided to determine that services rendered were medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health procedures and services have not been met.Therefore, we decided that the Plan does not have to pay forhome health procedures and services (99509) provided February 1, 2020 to May 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetwo skilled nursing visits (G0299).You asked the Plan to pre-approvetwo skilled nursing visits. You say that the services are medically necessary.The Plan denied your request. The Plan says your medical conditions, medication management, pain management, and household safety have been reviewed with you and your caregiver(s). The records do not support the need for a skilled nurse to make more visits.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 two skilled nursing visits. Our reviewer says that the service is not medically necessary our physician reviewer found the documentation doesn't support that you require skilled nursing servicesor skilled rehab services to provide treatment that is medically necessary.