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

We decided that the Plan does not have to waive the copayment for the injection provided on June 13, 2019.
You asked the Plan to waive the copayment for the injection. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received injection services provided at an ambulatory surgical center on June 13, 2019. The Plan states the correct copayment has applied per your contract with the Plan.
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 $395 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center. We looked at the file, the Plan's contract and Medicare rules. The file shows you received an injection on June 13, 2019 provided to you at an ambulatory surgical center. You have been asked to pay a $395 copayment for the injection. The injection, when provided in an ambulatory surgical center, falls within the Outpatient surgery and Other Medical 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 copayment for the injection provided on June 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 10mg triamcinolone acetonide injections (J3301) provided on September 23, 2019.
You asked the Plan to pay for the triamcinolone acetonide. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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. In this case, the CPT Code Manual definition of code J3301 is Injection, triamcinolone acetonide, not otherwise specified, 10 mg. We asked our coder 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 the triamcinolone acetonide. Our reviewer says that CPT code J3301 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical documentation does not accurately document the strength/dosage of the medication that was administered, therefore, this service cannot be validated. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the triamcinolone acetonide have not been met. Therefore, we decided that the Plan does not have to pay for 10mg triamcinolone acetonide injections (J3301) provided on September 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2020) purchased May 14, 2019.You asked the Plan to pay for vision care. You say that you purchased 2 pairs of eyeglasses 1 pair as your cataract glasses and the other pair as a spare. You paid $249 for the two pairs of eyeglasses and is entitled to $100 reimbursement but only received $124.98.The Plan denied your request. The Plan says this claim was processed correctly and the plan reimbursed the enrollee for the full amount that was paid by the enrollee.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 up to $100 eyewear benefit for non-Medicare covered.We looked at the file and the Plan's rules. The plan had reimbursed $124.98 to the enrollee. The enrollee was not assessed any cost share per the plan benefit. Based on this information, we decided that the Plan's rules for coverage of vision care have not been met.Therefore, we decided that the Plan does not have to pay for deluxe frames (V2020) purchased May 14, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided at an ambulatory center on January 29, 2020.
You asked the Plan to waive the copayment for a colonoscopy. You say that this colonoscopy was approved. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for outpatient surgery/ambulatory surgical center. You have been asked to pay a $200 copayment for a colonoscopy. Plan approved services are still subject to the correct cost-sharing amount; therefore, the correct copayment has been applied to the services that were provided. A colonoscopy falls within the outpatient surgery/ambulatory surgical center benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a colonoscopy provided at an ambulatory center on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound of the cornea and related services (92020, 92133, 92083, 76514) provided on November 22, 2019.You asked the Plan to pay for the ophthalmological services. You say that the services were medically necessary and you wanted a second opinion.The Plan denied your request. The Plan says there were network providers available that could provide the non-emergent services at issue.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 ultrasound of the cornea and related services (92020, 92133, 92083, 76514) provided on November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided by a participating provider on November 9, 2018 to December 14, 2018.
You asked the Plan to waive the copayment for wound care. You say that you did not have surgery. You say that you should only have a $40 copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for outpatient surgery/outpatient hospital setting. You have been asked to pay a $275 copayment for wound care. The total amount you are being asked to pay is $825 ($275 x 3 visits = $825). Wound care is considered an outpatient surgery; therefore, the correct copayment has been applied. Wound care falls within the outpatient surgery/outpatient hospital setting 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 wound care provided by a participating provider on November 9, 2018 to December 14, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you believe there is a coding error in the
claim submitted to the Plan. You say that you have tried to contact the provider several times in an attempt to
have the claims corrected. You stated that many times the reason for an EMT call can be resolved without
transport, however it is then financially more expensive for the patient to not be transported than to take the trip
to an emergency facility. You say that it would make more financial sense for the Plan to allow coverage for a
no transport event. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on November 11, 2018. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home visit assistance.

You asked the Plan to pre-approve home visit assistance. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 

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 home visit assistance. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no identified skilled nursing or physical therapy need. When Home Health Aide services are requested and are not in support of a skilled need, the service is not considered 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 home visit assistance have not been met. Therefore, we decided that the Plan does not have to pre-approve home visit assistance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine eye wear to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve routine eye wear. You say that you cannot see properly with the new glasses
you received from the in network provider. The Plan denied your request. The Plan says there are in-network
providers that are able to provide these services. Therefore, coverage criteria has not been met.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
routine eye wear to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy provided on October 8, 2019.You asked the Plan to pay for the endodontic therapy. You say that normally you have coordination of benefits for dental services. You also say that your primary picks up the bill and then the Plan takes care of the balance.The Plan denied your request. The Plan says the treating provider is out-of-network with the Plan. The Plan also says that out-of-network dental providers can bill you for the difference between their billed amount and the paid amount.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 out-of-network.Therefore, we decided that the Plan does not have to pay for the endodontic therapy provided on October 8, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran ECG provided on October 1, 2019 by an out of network (OON) provider.You asked the Plan to pay foran ECG. You say that these services are referred by the patient's in-network provider.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.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 foran ECG provided on October 1, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Transcranial Magnetic Stimulation (TMS). You asked the Plan to pre-approve the Transcranial Magnetic Stimulation. You say that the services are medically necessary.The Plan denied your request. The Plan says coverage criteria is not met.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 Transcranial Magnetic Stimulation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation presented from the previous Transcranial Magnetic Stimulation (TMS) performed in October to December 2019 showed less than a 50 percent improvement of the depression based on the PHQ 9. Based on the information provided, this patient does not meet the clinical criteria for the use of TMS therapy.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 Transcranial Magnetic Stimulation have not been met.Therefore, we decided that the Plan does not have to pre-approve Transcranial Magnetic Stimulation (TMS).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the eyewear provided on December 13, 2019.You asked the Plan to provide additional payment for the eyewear. The Plan denied your request. The Plan says that your benefit was exhausted with this purchase.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 up to a $150 allowance for eyewear every 12 months.We looked at the file and the Plan's rules. The file shows that the plan has approved the maximum yearly benefit of $150 for the requested services. There is no provision in the contract which would require the plan to approve more than this amount.Therefore, we decided that the Plan does not have to provide additional payment for the eyewear provided on December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a power seat elevation system (E2300) provided on August 5, 2019.
You asked the Plan to pay for the power seat elevation system. You say that you would like reconsideration because this accessory is medically necessary. The Plan denied your request. The Plan says a power seat elevation system can be added to a group 2 power wheelchair.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a power seat elevation system (E2300) provided on August 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvefoot orthotics.You asked the Planto pre-approvefoot orthotics. You say that the enrollee has severe rheumatoid arthritis.The Plandenied your request. The Plansaysthis 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 does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate, neither Medicare nor the Plan provides coverage of orthotics for condition.Therefore, we decided that the Plandoes not haveto pre-approvefoot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis RT (L1833) and suspension sleeve RT (L2397)
provided December 12, 2019.
You asked the Plan to pay for the orthoses. You say that the records should support the necessity of the service
in dispute. The Plan denied your request. The Plan says the records provided do not support the service billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain proof of delivery documentation for the items
at issue in this appeal. The record does not contain a valid proof of delivery or an itemized shipping/billing
invoice for the supplies provided in this case. The delivery ticket did not include the carrier's tracking number.
The proof of delivery did not include an order number or details to corroborate the delivery ticket submitted.
Therefore, we decided that the Plan does not have to pay for knee orthosis RT (L1833) and suspension sleeve
RT (L2397) provided December 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee braces (L1833 and L2397) provided on November 21, 2019. You asked the Plan to pay for the knee braces. 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 knee braces have not been met. Specifically, the record indicates that the Plan requested documentation to validate an established relationship with the ordering physician, along with documentation of the duration of the patient's condition, clinical course (worsening or improving), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, and previously received DME items related to the billed items. There is insufficient information to validate the billed supply codes. Therefore, we decided that the Plan does not have to pay for knee braces (L1833 and L2397) provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous stabilization device
(Superion IDS).
You asked the Plan to pre-approve Superion IDS. You say that this procedure is covered and is medically
necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this
service is correct, because studies are lacking when comparing this procedure to the results obtained from
traditional surgical decompression and the long-term safety, efficacy, and durability of this device has not been
established.
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 Superion IDS. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this procedure is experimental and more research is needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Superion IDS have not been met. Therefore, we decided that the Plan does not
have to pre-approve insertion of an interspinous stabilization device (Superion IDS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the mastectomy sleeve purchased on October 5, 2018.
You asked the Plan to reimburse you for the mastectomy sleeve. You say that the sleeves are a medical necessity and you cannot afford them. The Plan denied your request. The Plan says mastectomy sleeves are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that mastectomy sleeves described by code L8010 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to reimburse you for the mastectomy sleeve purchased on October 5, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extraspinal manipulation (98943) and therapeutic procedures (97150 and 97110) provided on September 12, 2019.
You asked the Plan to pay for the extraspinal manipulation and therapeutic procedures. You say that you would like reconsideration because these services will help to prevent further deterioration. The Plan denied your request. The Plan says they only cover manual manipulation of the spine to correct subluxation.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for extraspinal manipulation (98943) and therapeutic procedures (97150 and 97110) provided on September 12, 2019.