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

We decided that the Plan does not have to pay forthe two onlaysprovided on January 14, 2021, and February 4, 2021.You asked the Plan to pay forthe onlays. You say that the onlays are restorative services.The Plan denied your request. The Plan says these services are not covered benefits.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 forthe two onlays provided on January 14, 2021, and February 4, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that you need this transportation to get to dialysis. The Plan denied your request. The Plan says that your request exceeds the benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of sixty (60) trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at an alternate level of care. 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the topical administration of aminolevulinic acid provided on November 19, 2020.

You asked the Plan to waive the coinsurance for the topical administration of aminolevulinic acid. You say that a mistake was made in charging you a copayment for a procedure that should have been fully covered. You say that the Plan should pay the dermatologist. 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 other Part B covered drugs.

You have been asked to pay $76.58, which is 20% of the allowed amount for the topical administration of aminolevulinic acid. The allowed amount is $382.91 (20% x $382.91 = $76.58). The topical administration of aminolevulinic acid falls 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 topical administration of aminolevulinic acid provided on November 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist physician services provided on August 31, 2020.
You asked the Plan to waive the copayment for the specialist physician services. You say that this was not an emergency visit and if your regular doctor had been available there would be no out-of-pocket charge. The Plan denied your request. The Plan says you were charged this copayment because you saw a specialist, not because it is considered an emergency 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 a $40 copayment for Physician Services, Specialist's Office. You have been asked to pay a $40 copayment for the specialist physician services. The doctor you saw is a specialist. The specialist physician services fall within the Physician Services, Specialist's Office 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 specialist physician services provided on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99238, 99231) provided December 23, 2020 to January 7, 2021.

You asked the Plan to pay for the hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 99238, & 99231 are not supported in the medical record. Specifically, the documentation provided does not support the billed codes. Additional records were requested by the plan and were not received. Based on this information, we decided that Medicare rules for coverage of the hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99238, 99231) provided December 23, 2020 to January 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient visit provided September 10, 2020.
You asked the Plan to waive the copayment for the outpatient visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $350 copayment for outpatient clinic services. You have been asked to pay the Medicare allowed amount of $129.47 for the outpatient visit. The outpatient visit falls within the outpatient clinic services benefit category. The allowable amount is less than the $350 copayment listed in the Evidence of Coverage. 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 visit provided September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pacemaker evaluation provided on October 9, 2020.

You asked the Plan to waive the copayment for the pacemaker evaluation. You say that you did not see a specialist that day you only had a pacemaker check. You say that you are requesting a waiver to not be responsible to pay the $35 charge. The Plan denied your request. The Plan says the copayment 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 a $35 copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under Medicare rules). 

You have been asked to pay a $35 copayment for the pacemaker evaluation. The pacemaker evaluation falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The pacemaker evaluation is considered a physician service. 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 pacemaker evaluation provided on October 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from September 29, 2020, to October 29, 2020.

You asked the Plan to pay for SNF care. You say that this was medically necessary, and the patient needed to be isolated. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that Type of Bill 21X and Revenue Code 0022 should be used for SNF inpatient services. 

We looked at the file and Medicare rules. The claim at issue was not billed with the correct Type of Bill and does not include Revenue Code 0022. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from September 29, 2020, to October 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and an intraoral periapical radiographic image (D0220) provided on February 26, 2021.
You asked the Plan to pay for a limited oral evaluation, and an intraoral periapical radiographic image. You say that you do not understand why the services are not covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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 a limited
oral evaluation (D0140), and an intraoral periapical radiographic image (D0220) provided on February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on December 31, 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 the claim was incorrectly billed.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the appropriate place of service (POS) code. 

We looked at the file and Medicare rules. The file shows that the office visit was billed with POS code 12 for the home setting and this is not an appropriate POS code for the services. 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 office visit rendered on December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathogen test panel provided on December 14, 2020.
You asked the Plan to pay for the testing services. You say that the lab provided timely testing and results. The Plan denied your request. The Plan says molecular genetic screening testing is not a Medicare 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. We looked at the file and the rules. In this case, there are insufficient medical records to show that the testing was necessary for the treatment of a urinary tract infection. The test at issue in this appeal was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the molecular pathogen test panel provided on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a musculoskeletal strengthening program provided from January 19, 2021, through February 9, 2021.
You asked the Plan to pay for the musculoskeletal strengthening program. You say that the musculoskeletal strengthening program is not an exercise program as it can be used to compliment a pharmaceutical treatment as a preventive protocol. The Plan denied your request. The Plan says the 2021 National Physician Fee Schedule lists HCPCS S9970 with a status indicator of "I", which indicates that this service is not valid for Medicare purposes.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of the health and wellness education programs have not been met because they are not being provided by the Plan's health and wellness education programs provider. Therefore, we decided that the Plan does not have to pay for a musculoskeletal strengthening program provided from
January 19, 2021, through February 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81120, 81173, 81121, 81201) provided October 15, 2020.
You asked the Plan to pay for genetic testing. You say that the testing was medically necessary. The Plan denied your request. The Plan says coverage criteria was not met.
The Plan follows Medicare rules. Medicare rules say that Guardant360 genetic testing is covered when medically necessary. 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 pay for genetic testing. Our reviewer says that the genetic testing was not medically necessary. Our physician reviewer found there is no staging or histology of the lung cancer provided. Limited clinical information on the tumor was provided. We looked at this physician's review, the file, and Medicare rules. 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 genetic testing (81120, 81173, 81121, 81201) provided October 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing panel services provided on February 1, 2021.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the screening testing is not a Medicare 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. 

The testing at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the testing panel services provided on February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lens enhancements, including photochromatic tinting (V2744), anti-reflective coating (V2750) and progressive lenses (V2781) purchased on February 2, 2021.

You asked the Plan to pay for lens enhancements. You say that you cannot afford this bill and you were told the eyeglasses would not go over your vision allowance. The Plan denied your request. The Plan says lens enhancements are not covered by your vision benefit but may be purchased by you for an additional cost. You did receive a discount for the enhancements, but they are not covered.

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 does not cover lens enhancements. 

We looked at the file and the Plan's rules. Although the Plan offers a supplemental vision benefit in excess of Medicare coverage, this benefit does not include lens enhancements. Therefore, we decided that the Plan does not have to pay for lens enhancements, including photochromatic tinting (V2744), anti-reflective coating (V2750) and progressive lenses (V2781) purchased on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the insertion or replacement of permanent pacemaker and upper chamber electrodes (33206) provided October 30, 2020.
You asked the Plan to waive the coinsurance for the pacemaker insertion. You say that you were quoted a cost share that is different than what you are being billed. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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 prosthetic devices and related supplies. You have been asked to pay a total cost share of $1,790.66 for the pacemaker insertion ($8,953.30 Medicare allowed amount x 20% coinsurance). This service falls within the prosthetic devices and related supplies
benefit category and not the outpatient surgery 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 insertion or replacement of permanent pacemaker and upper chamber electrodes (33206) provided October 30, 2020.
Your complaint about potentially receiving misinformation regarding your cost share is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for myocardial perfusion imaging, planar (78454) provided June 8, 2020.
You asked the Plan to pay for the diagnostic service. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Procedure code incidental to primary procedure.
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, we have confirmed that code the diagnostic service has a bundled relationship with code 78451 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for myocardial perfusion imaging, planar (78454) provided June 8, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided from February 26, 2019, to December 4, 2019.
You asked the Plan to pay for psychotherapy. You say that although the provider had opted out of Medicare you thought you could get reimbursement. The Plan denied your request. The Plan says payment cannot be made for a provider who chose not to receive Medicare funds.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from February 26, 2019, to December 4, 2019.