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

We decided that the Plan does not have to pay for the excision of benign lesion up to 1.25 cm (D7410) provided April 12, 2021.

You asked the Plan to pay for the excision. You say that the service should be covered because you had it taken care of once it became necessary. The Plan denied your request. The Plan says this service is not covered under your dental 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 the excision of benign lesion up to 1.25 cm (D7410) provided April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided March 24, 2021.

You asked the Plan to pay for the panoramic x-ray. You say that you are frustrated with the Plan's coverage. The Plan denied your request. The Plan says this service is not covered under your 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 the panoramic radiographic image (D0330) provided March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided December 1, 2020.

You asked the Plan to pay for the lab services. 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 code G0483 is not supported in the medical record. Specifically, the place of services on the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on April 6, 2021.

You asked the Plan to pay for the foot inserts. You say that you have serious foot pain and need the inserts to help you to keep on walking and exercising. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that
includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water
and/or phone bill payments (debit card), home assistance services (repairs).

You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes
transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or
phone bill payments (debit card), home assistance services (repairs). You say that you suffer from arthritis of
the knee. The Plan denied your request. The Plan says the enrollee has none of the qualifying diagnoses, does
not require intense care coordination, and has no high risk for hospitalizations or high risk for adverse health
outcomes.

The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you
must have one or more comorbid and medically complex chronic conditions that are life-threatening or
significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization
or other adverse health outcomes; and must require intensive care coordination.

We looked at the file and Plan's rules. The file shows that your medical conditions are not eligible medical
conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to preapprove
special supplemental benefits for the chronically ill that includes transportation for non-medical needs,
an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home
assistance services (repairs).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020) and progressive lenses (V2781) provided on April 16, 2021.
You asked the Plan to pay for eyeglass frames and progressive lenses. You say that you have been seeing the same eye doctor for your diabetic exams and you do not want to see another eye doctor. The Plan denied your request. The Plan says frames and lenses will only be covered when they are received from a provider in the specified vision network.
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 gives you a $100 allowance every year towards frames and lenses purchased from a network provider. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. The Plan covers eyewear when they are received from a provider who participates in the Plan's specified vision network. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020) and progressive lenses (V2781) provided on April 16, 2021
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
November 25, 2020.
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on November 15, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on November 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted supplies and materials (99070) provided July 1, 2020 to November 1, 2020.

You asked the Plan to pay for the unlisted supplies. You say that there were 2 out of pocket over payments to the Plan that need to be refunded. Please send back a check for $140.24 to cover the overpayments. The Plan denied your request. The Plan says an itemized bill was requested form the provider and was not received.

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 code 99070 is not supported in the medical record. Specifically, the record does not contain an itemized bill for the dates of service. The record shows that the Plan made several attempts to obtain the requested additional information without success. Therefore, we decided that the Plan does not have to pay for unlisted supplies and materials (99070) provided July 1, 2020 to November 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that
includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water
and/or phone bill payments (debit card), home assistance services (repairs).

You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes
transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or
phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan
says the enrollee has a cardiovascular disorder (hypertensive disease), but does not require intense care
coordination, and has no high risk for hospitalizations or high risk for adverse health outcomes.

The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you
must have one or more comorbid and medically complex chronic conditions that are life-threatening or
significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization
or other adverse health outcomes; and must require intensive care coordination.

We looked at the file and Plan's rules. The file shows that your medical conditions are not eligible medical
conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve
special supplemental benefits for the chronically ill that includes transportation for non-medical needs,
an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home
assistance services (repairs).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services you received on March 17, 2021.

You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says out-of-network services are not 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 services are not among those covered under this benefit. The services in question were provided to you by an out-of-network dental provider. The Plan does not cover out-of-network dental services. Therefore, we decided that the Plan does not have to pay for the dental services you received on March 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient hospital services provided on
March 18, 2021.

You asked the Plan to waive the cost share for the transthoracic echocardiography (C8929) and myocardial
perfusion imaging (78452). You say that you shouldn't have had to pay. The Plan denied your request. The
Plan says you were charged this cost share 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 $250
copayment for nuclear medicine services and 20% coinsurance for diagnostic procedures and tests for
Outpatient Hospital Services.

You have been asked to pay $250 for the myocardial perfusion imaging (78452) and 20% coinsurance for the
transthoracic echocardiography (C8929). The transthoracic echocardiography (C8929) and myocardial
perfusion imaging (78452) fall within the Outpatient Hospital Services benefit category. This means that you
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the cost share for the outpatient hospital services provided on March 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a CardioMEMS device (C2624, 33289).

You asked the Plan to pre-approve the insertion of a CardioMEMS device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental for the enrollee's condition.

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 insertion of a CardioMEMS device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the CardioMEMS pressure sensor monitoring device implantation has been Food and Drug Administration (FDA) approved and has published literature to support its use in patients on full guideline directed medical therapy who have NYHA Class III symptoms despite medical therapy and a hospitalization within the past 12 months for decompensated congestive heart failure (CHF). This patient has a history of ischemic cardiomyopathy and persistent dyspnea. However, he has no documented recent hospitalizations related to decompensated CHF. 

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 insertion of a CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a CardioMEMS device (C2624, 33289).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine rendered on March 18, 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 service are not covered.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine rendered on March 18, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 28, 2020.

You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for laboratory services provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (99349) provided on February 1, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for a home visit. You say that this is supported by the records. The Plan denied your request. The Plan says this was not authorized.

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 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 a home visit (99349) provided on February 1, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214), the interlaminar lumbar injection (62323), the epidurography (72275), the triamcinolone acetonide injection (J3301), and the low osmolar contrast material, 200-299 mg/ml iodine concentration (Q9966) rendered by the out-of-network (OON) provider on March 3, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider, without prior authorization.

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 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 office visit (99214), the interlaminar lumbar injection (62323), the epidurography (72275), the triamcinolone acetonide injection (J3301), and the low osmolar contrast material, 200-299 mg/ml iodine concentration (Q9966) rendered by the out-of-network (OON) provider on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair.

You asked the Plan to pay for a shower chair. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the item is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on March 16, 2021.
You asked the Plan to pay for an eye refraction. You say that you had an eye exam on October 19, 2020 but
your vision deteriorated in 2021 and you needed another eye exam. You also say you would like your claim to
be reconsidered. The Plan denied your request. The Plan says you exhausted your vision benefit.
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 contract also says that you receive a vision eye exam and refraction every 12 months.
We looked at the file and the Plan's rules. The records show you had an eye exam on October 21, 2020. The
records also show you have exhausted your vision benefit. Based on this information, we decided that the
Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not
have to pay for an eye refraction (92015) provided on March 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be optimally restored at any other level of care and is at risk of further medical decline. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee was admitted with acute on chronic respiratory failure due to chronic obstructive pulmonary disease and pneumonia. The enrollee continues to improve and has no ventilator or wound care needs. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.