Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 10, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says there is no valid referral for this service.Medicare rules say that plans can requireenrollees 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 service 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 subsequent nursingfacility care providedon December 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea standard wheelchair and a manual fully reclining back option.You asked the Plan to pre-approvethese services. You say that this will be beneficial for transporting to testing and doctor visits. The Plan denied your request. The Plan says that equipment for use outside of the home is not covered.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea standard wheelchair and a manual fully reclining back option.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan has to waive the copayment foran ERvisit provided on December 13, 2019.You asked the Plan to waive the copayment foran ER visit. You say that you were admitted inpatient and should not owe an ER copayment.The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged thecorrect amount.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 enrollees must pay a $100 copayment for emergency care. The copayment is waived if you are admitted to the hospital as an inpatient andfor observation stays.The Plan says you must pay a $100 copayment for an ER visit. Based on the Plan contract, however, you cannot be asked to pay for an ER visitif you are admitted to the hospital.Therefore, we decided that the Plan has to waive the copayment foran ERvisit provided on December 13, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on October 10, 2019.
You asked the Plan to pay for the hearing aids. You say that you did not know you needed to get a referral. The Plan denied your request. The Plan says that hearing aids purchased out of network is not a covered benefit
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they select the provider or vendor. We looked at the file and the Plan's rules. The file indicates the Plan did not approve the vendor who provided the hearing aids. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on October 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on August 8, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.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 tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833 and L2397).
You asked the Plan to pay for the orthosis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Specifically, the record indicates that the Plan requested documentation to validate an established relationship with the ordering physician. There is insufficient information to validate the billed services. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833 and L2397)..
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forwound debridement provided from September 14, 2019 to November 1, 2019.You asked the Plan to waive the copayments forwound debridement. You say that you disagree with the chargesand feel that you should only owe a $20 copayment per visit.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for each covered outpatient surgery service provided in an outpatient hospital facility.You received wound debridement from September 14, 2019 to November 1, 2019 for a total of 3 visits. Wound debridement is considered an outpatient surgical procedure. Therefore, the total amount you owe is: $225 (copayment) x 3 (surgery services) = $675.You have been asked to pay the total copayment amount of $675 for wound debridement. Wound debridement falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forwound debridement provided from September 14, 2019 to November 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-rays provided on October 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for x-rays. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 x-rays provided on October 16, 2019 by an out of network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient procedure (CPT 36246-50) provided on July 31, 2019.
You asked the Plan to pay for the outpatient procedure. You say that you received authorization from the Plan for CPT codes 37720, 37222 and 37223 and the procedure performed and billed (CPT 36246-50) falls under the same description and should be paid. The Plan denied your request. The Plan says prior authorization for the procedure that was performed was not obtained.
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 outpatient procedure (CPT 36246-50). We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the outpatient procedure (CPT 36246-50) provided on July 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a temporary partial upper denture (D5820) and a temporary partial lower denture (D5821). You asked the Plan to pre-approve the dental services. You say that for health reasons, you cannot have x-rays,
anesthetic, or metal in your mouth as you are chemically sensitive. You say that you are able to afford temporary partials with your dental benefit, but not permanent ones. You also say that you did not use any of your dental benefit in 2019. The Plan denied your request. The Plan says temporary partial dentures are not a covered service. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested temporary partial
dentures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a temporary partial upper denture (D5820) and a temporary partial lower denture (D5821).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on March 28, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on March 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the seven extractions of erupted teeth requiring removal of bone and/or sectioning of tooth, two bone replacement grafts for ridge preservation, and four extractions of erupted teeth or exposed roots provided by an OON provider on November 12, 2019.
You asked the Plan to pay for the extractions and bone replacement grafts. You say that when you asked the Plan, they told you that you could see out-of-network providers with a referral from your main doctor. You also say that you did get approval from your doctor for these services. The Plan denied your request. The Plan says the rendering provider is not a part of the Plan's dental network.
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 covered when they are received OON. The records show that a representative from this provider's office spoke with the Plan and was advised that you did not have any out-of-network benefits. Therefore, we decided that the Plan does not have to pay for the seven extractions of erupted teeth requiring removal of bone and/or sectioning of tooth, two bone replacement grafts for ridge preservation, and four extractions of erupted teeth or exposed roots provided by an OON provider on November 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for crown -porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950) provided to the enrollee from April 24, 2019 through May 14, 2019.You asked the Plan to pay forthe dental services. You say that you were unaware the dental procedures were not covered services under the member's plan.The Plan denied your request. The Plan says the services are 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. The services are not listed in the enrollee's EOC as a covered benefit; therefore, the services are not covered.Therefore, we decided that the Plan does not have to pay for crown -porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950) provided to the enrollee from April 24, 2019 through May 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesyringes for a self-administered drug.You asked the Plan to pre-approvesyringes. You say that you need syringes for a prescribed self-administer vitamin.The Plan denied your request. The Plan says Medicare does not cover vitamins, or supplements, or the syringes to inject them.The Plan must follow Medicare rules. Medicare rules say that supplies used withself-administered drugs are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of syringes have not been met.Therefore, we decided that the Plan does not have to pre-approvesyringes for a self-administered drug.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from October 26, 2019 through November 7, 2019and November 15, 2019 through November 24, 2019.You asked the Plan to pay for SNF care. You say that the stay was 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 above 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 pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 pay for SNF care provided to the enrollee from October 26, 2019 through November 7, 2019 and November 15, 2019 through November 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe refraction provided on October 29, 2019.You asked the Plan to pay forthe refraction. The Plan denied your request. The Plan says that you have exceeded limits set in the subscriber agreement.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 one eye exam per year.We looked at the file and the Plan's rules. The file indicates the Plan provided coverage for a refraction on February 21, 2019. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met.Therefore, we decided that the Plan does not have to pay forthe refraction provided on October 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on September 26, 2019.You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 the lab services provided to the enrollee on September 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe panoramic x-ray (D0330) and filling (D2392) provided from October 8, 2019 to November 12, 2019.You asked the Plan to pay forthe dental services. You say that the provider's office did not advise that the services would not be covered. You also say that you were not given a choice as to whether or not you received the services.The Plan deniedyour request. The Plan says panoramic x-rays are not listed as a covered service. The Plan also says that filling are not a covered service either.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 panoramic x-ray and filling are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe panoramic x-ray (D0330) and filling (D2392) provided from October 8, 2019 to November 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more forthe osseous surgery (D4260) provided on December 6, 2019.You asked the Plan to pay more forthe dental service. You say that the $41 allowed amount for the surgery does not seem just. You also say that you are on a limited income.The Plan denied your request. The Plan says that the allowed amount for the osseous surgery is $141. The Plan says there is a $100 deductible that must be met before covered services can be paid. The Plan also says there is a 50% coinsurance for endodontic, periodontics and oral surgery services.Medicaregenerally 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, there is a $100 deductible that must be met before covered services can be paid by the Plan.Therefore, we decided that the Plan does not have to pay more for the osseous surgery (D4260) provided on December 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite
You asked the Plan to pay for dental composite. You say that this tooth was broken after a fall and needed repair. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this procedure is only covered once per 12 months per tooth and was provided to you less than 12 months before this service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dental composite once per 12 months per tooth per surface. We looked at this physician's review, the file, and Medicare rules. You received this procedure on the same tooth and surface less than 12 months before this service was performed. The treating provider gave you advanced notice that this service would not be covered by the Plan. Based on this information, we decided that the Plan's rules for coverage of dental composite have not been met. Therefore, we decided that the Plan does not have to pay for resin-based composite
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intravitreal injection of a pharmacologic agent and aflibercept injection provided on November 6, 2019.You asked the Plan to pay for intravitreal injection of a pharmacologic agent and aflibercept injection. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 67028 is intravitreal injection of a pharmacologic agent (separate procedure).The CPT Code Manual definition of code J0178 is injection, aflibercept, 1 mg.We find that CPT codes 67028 and J0178 are not supported in the medical record. Specifically, the documentation does not indicate that intravitreal injection of a pharmacologic agent was administered.The documentation also does not indicate that injection, aflibercept, 1 mg was administered.Based on this information, we decided that Medicare rules for coverage of intravitreal injection of a pharmacologic agent and aflibercept injection have not been met.Therefore, we decided that the Plan does not have to pay for intravitreal injection of a pharmacologic agent and aflibercept injection provided on November 6, 2019