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

We decided that the Plan has to pay for refraction services (92015) provided September 30, 2020.
You asked the Plan to pay for the vision services. You say that your plan covers one eye exam a year. According to the records, you were eligible since 12/31/2016. All the other tests were covered but not the exam for the glasses. The Plan denied your request. The Plan says that these services are covered but the claim has to be submitted to the supplemental plan. Details of the services were sent to the supplemental plan and they responded stating no claim on file for rendered services.
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 these services when completed as part of a routine eye exam. We looked at the file and the Plan's rules. The vision coverage includes 1 routine eye exam per calendar year. Eye exam will include refraction and dilation. Based on this information, we decided that the Plan's rules for coverage of the vision services have been met. Therefore, we decided that the Plan has to pay for refraction services (92015) provided September 30, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute.
You asked the Plan to pre-approve these services. You say that you need surgery on your foot and will be non-weight bearing for six to eight weeks. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a crutch substitute (E0118) is denied as not medically necessary. We looked at the file and Medicare rules. The requested services are a crutch substitute. These services are denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for IV tubing (S1015) and infection control supplies (S8301) provided on June 29, 2020.
You asked the Plan to pay for the IV tubing and infection control supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT codes S1015 and S8301 have a status indicator of I and are not valid for Medicare purposes.
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 S1015 and S8301 are not supported in the record. Specifically, per the Physician Fee Schedule, CPT codes S1015 and S8301 have a status indicator of I. This means that CPT codes S1015 and S8301 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the IV tubing and infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for IV tubing (S1015) and infection control supplies (S8301) provided on June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), pulp vitality tests (D0460), the root canal (D3330), and the treatment of root canal obstruction (D3331) provided on November 19, 2020.
You asked the Plan to pay for the dental services. You say that coverage was approved before you received the services. The Plan denied your request. The Plan says pulp vitality test is not listed as a covered service. The Plan says root canal is not listed as a covered service. The Plan says treatment of root canal obstruction is not listed as a covered service either. The Plan says that 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit for this service has been exceeded.
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 pulp vitality tests, the root canal, and the treatment of root canal obstruction are not among those covered under this benefit. Additionally, the frequency limit of 1 limited oral evaluation per plan year has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on November 23, 2020. The record also shows that you signed treatment plan dated November 19, 2020 received from provider showing member accepted treatment estimate based on insurance information presented. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), pulp vitality tests (D0460), the root canal (D3330), and the treatment of root canal obstruction (D3331) provided on November 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. You say that the enrollee needs to regain strength. The Plan
denied your request. The Plan says the enrollee's needs are mostly custodial in nature.

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 services. Our physician reviewer
found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, and was
treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services,
the enrollee was at a minimal assist level for functional mobility. Although there are identifiable skilled therapy
service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. He does not
meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Purewick External Catheter System (A9270).
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item does not meet Medicare criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that the use of the appropriate HCPCS code assures that accurate processing can be accomplished resulting in a proper claim determination and reimbursement. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Specifically, these rules say that the PDAC reviews items and assigns codes. The PDAC product classification listing is evidence of correct coding for a particular item. The PDAC assigned the Purewick system a code of A9270, which is for a noncovered item/service. As the correct code for this item is a noncovered code, we find that Medicare rules do not allow coverage of this device/system. Therefore, we decided that the Plan does not have to pre-approve a Purewick External Catheter System (A9270).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 19, 2020.
You asked the Plan to pay for the services provided. You say that the claim is not inclusive to the enrollee's post-op services. The Plan denied your request.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation.
We find that the services at issue are not supported in the medical record. Specifically, there are insufficient records to show that the catheter placement and subsequent hospital care services were not related to the surgery provided on July 2, 2020. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission provided from August 31, 2020, to September 29, 2020.
You asked the Plan to pay for the SNF admission. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the SNF admission is not medically necessary. The Plan says that the enrollee has no documented skilled therapy needs.
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 pay for the SNF admission. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission provided from August 31, 2020, to September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99213) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that due to COVID you are temporarily living in Connecticut. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 the outpatient office visit (99213) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided from June 12, 2020, through September 5, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that in most cases care received from an out of network provider will not be covered.
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 physician's services. 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 physician's services that you provided from June 12, 2020, through September 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upgraded electronics (electronic connection, expandable controller and harness) and a seat lift
You asked the Plan to pre-approve upgraded electronics and a seat lift. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. In addition, the requested electronic connection, expandable controller, and expandable controller harness cannot be covered as they are not medically necessary to control the three approved power options through the joystick. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of upgraded electronics and a seat lift have not been met. Therefore, we decided that the Plan does not have to pre-approve upgraded electronics (electronic connection, expandable controller and harness) and a seat lift
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing.
You asked the Plan to pay for the CxBladder testing. You say that you would like reconsideration is eligible for payment as it meets medical necessity guidelines. The Plan denied your request. The Plan says Medicare reaffirmed noncoverage for CPT codes 0012M and 0013M for CxBladder.
The Plan must follow Medicare rules. Medicare rules say that for the CxBladder assay coded as 0013M , non-coverage was reaffirmed by Medicare as of revisions made to the guidelines on October 4, 2018. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CxBladder testing have not been met. Specifically, this testing is not a Medicare covered benefit. Therefore, we decided that the Plan does not have to pay for the CxBladder testing.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the shoulder orthosis (L3670) provided on September 29, 2020.
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the item was rendered by an out of network provider, without prior authorization.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care. We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have been met. Specifically, the enrollee went to an urgent care facility while out of the service area, due to unforeseen pain in his shoulder. The shoulder orthosis was provided subsequently thereafter this visit. It was reasonable for the enrollee to obtain the orthosis from the provider and not to delay treatment of his shoulder before returning to the service area. Therefore, we decided that the Plan has to pay for the shoulder orthosis (L3670) provided on September 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from September 4, 2020, to September 10, 2020.
You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says there were no skilled services provided on the dates of service in this case. The Plan also says that by September 4, 2020 no longer need daily skilled care from either a nurse or a therapist.
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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing
and/or skilled therapy on an inpatient basis in a SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from September 4, 2020, to September 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor supplies.
You asked the Plan to pre-approve continuous glucose monitor supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested supplies.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitor supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions.

You asked the Plan to pre-approve dental extractions. You say that your condition causes severe bone loss and mobility. The Plan denied your request. The Plan says the benefit has been exhausted.

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.

We looked at the file, and Medicare rules. The file shows that 6 extraction procedures were originally requested. The plan approved 2 extraction procedures. Your plan only covers 2 extractions per calendar year. Therefore, we decided that the Plan does not have to pre-approve additional dental extractions.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vascular surgeon services to be provided by an OON
provider.

You asked the Plan to pre-approve OON services. You say that it would not be feasible for the enrollee to go to
an in-network provider due to transportation issues. The Plan denied your request. The Plan says in-network
surgeons are well within the distance that Medicare requires.

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 services at issue in this appeal. We were able to confirm that the Plan has
contract providers located within reasonable distance and travel time from your home who can provide the
services at issue. We found no exception that would require the Plan to pre-approve these OON services.
Therefore, we decided that the Plan does not have to pre-approve vascular surgeon services to be provided by
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pedal bike (E1399).

You asked the Plan to pre-approve the pedal bike. You say that this item is necessary for the enrollee. The Plan denied your request. The Plan says this is not a Medicare covered benefit.

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 pre-approve the pedal bike (E1399).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the laparoscopy provided on November 2,
2020.
You asked the Plan to waive the coinsurance for the laparoscopy. You say that this bill was not explained to
you before your surgery. The Plan denied your request. The Plan says you have been asked to pay the correct
cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance per visit.
You have been asked to pay $1,788.53 which is 20% of the allowed amount for the laparoscopy. The allowed
amount is $8,942.66. ($8,942.66 x 20% = $1,788.53). The laparoscopy 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 coinsurance for the laparoscopy provided on November 2, 2020.
Your complaint that you were rushed out the door of the hospital 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.