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

We decided that the Plan does not have to waive the cost sharing for the podiatry services rendered on January
12, 2021 to April 14, 2021.
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges.
The Plan denied your request. The Plan says the cost sharing was applied correctly.
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 there is $750 yearly deductible for your covered medical services and pay a $35
copayment after the deductible is met for each Medicare-covered podiatry visit.
Review of the file shows that you had a podiatry office visit and surgical services (debridement of nails) on
January 12, 2021. You have been asked to pay a $35 copayment for the office visit. These services fall within
the Medicare-covered podiatry visit benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. The Plan applied a deductible charge for your surgical services received on January 12, 2021, for a total of
$141.55. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 yearly
deductible for your covered medical services. This cost sharing is a contractual obligation that had not been
met at the time these services were received on January 12, 2021.
The file shows that you received surgical podiatry services on February 23, 2021 in the form of cutting of
lesions and wound debridement. The Plan applied a deductible charge for your surgical services received on
February 23, 2021, for a total of $165.72. The Plan has followed Medicare rules by clearly disclosing in the
contract that there is $750 yearly deductible for your covered medical services. This cost sharing is a
contractual obligation that had not been met at the time these services were received on February 23, 2021.
The file shows that you had a podiatry office visit and surgical services (debridement of muscle) on April 14,
2021. You have been asked to pay a $35 copayment for the office visit. These services fall within the
Medicare-covered podiatry visit benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan.
The Plan applied a deductible charge for your surgical services received on April 14, 2021 for a total of
$231.08. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 yearly
deductible for your covered medical services. This cost sharing is a contractual obligation that had not been
met at the time these services were received on April 14, 2021.
Therefore, we decided that the Plan does not have to waive the cost sharing for the podiatry services rendered
on January 12, 2021 to April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a medical eye exam (92014), an eye refraction (92015) and
an eye exam with photos (92250) provided on February 11, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a medical eye exam, refraction and photos. You say that a prior authorization is
not needed. The Plan denied your request. The Plan says services were provided 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 medical eye exam (92014), an eye refraction (92015) and an eye exam with photos (92250) provided on February 11, 2021, by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for trifocal lenses (V2399), lens tint (V2744), scratch resistant coating (V2760), ultraviolet lenses (V2755) and miscellaneous integral lenses (S0590) provided on April 4, 2021.
You asked the Plan to pay for trifocal lenses, lens tint, scratch resistant coating, ultraviolet lenses and miscellaneous integral lenses. You say that you were advised that you could receive vision benefits every 11 months and you need to get your vision checked yearly. The Plan denied your request. The Plan says you have 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 covers these services when The Plan contract says that you pay a $0 copay for up to 1 pair of eyeglass lenses (standard plastic single, bifocal, trifocal, or lenticular lenses) every 2 calendar years. We looked at the file and the Plan's rules. The records show that you purchased eyeglasses and lenses on May 7, 2020; therefore, you have exhausted your maximum allowed vision benefit. Based on this information, we decided that the Plan's rules for coverage of trifocal lenses, lens tint, scratch resistant coating, ultraviolet lenses and miscellaneous integral lenses. have not been met. Therefore, we decided that the Plan does not have to pay for trifocal lenses (V2399), lens tint (V2744), scratch resistant coating (V2760), ultraviolet lenses (V2755) and miscellaneous integral lenses (S0590) provided on April 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the revascularization services coded 37221 provided on January 14, 2021.
You asked the Plan to pay for the revascularization services. 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 payable.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 37221 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the revascularization services have not been met. Therefore, we decided that the Plan does not have to pay for the revascularization services coded 37221 provided on January 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (50820, 38571) provided to the enrollee on August 10, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says these codes were already allowed on a previous claim, which was billed by the same provider, same date of service, and same diagnosis codes.
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 the denied codes is: CPT 50820: Connection of urinary duct (ureter) to small bowel with creation of opening CPT 38571: Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation includes a statement claim number 820202370258201 with received date August 24, 2020 for CPT 50820 and CPT 38571 as being reimbursed. The documentation also includes a statement claim number 820203650391989 with received date December 30, 2020 for CPT 50820 and CPT 38571 as being denied. Both claims are date of service August 10, 2020, this resulted in duplicate billing, therefore, claim number 820203650391989 would not be covered. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (50820, 38571) provided to the enrollee on August 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that the the member needs continued therapy and is medically stable for transfer. The Plan denied your request. The Plan says that the enrollee does not require daily skilled nursing services.

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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for the upper and lower right quadrants and the lower left quadrant.
You asked the Plan to pre-approve periodontal scaling and root planing. You say that you need these services done as soon as possible to protect your teeth. The Plan denied your request. The Plan says these services can only be covered once every 24 months, and you had this service provided for these quadrants less than 24 months ago.
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, these services are requested in a frequency that is not covered under this benefit. Documentation shows that you have had periodontal scaling and root planing provided for the requested quadrants in 2020, and these services were paid for by the Plan at that time. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for the upper and lower right quadrants and the lower left quadrant.
Your complaint about dissatisfaction with the services covered by the Plan's supplemental benefit is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a gym membership for the 2020 benefit allowance.

You asked the Plan to reimburse you for a gym membership. You say that the enrollment period for the gym membership was affected by the pandemic. You also say that the facility closed following state protocols and reopened February 2021. The Plan denied your request. The Plan says payment was made to the fitness facility on March 15, 2021; therefore, this cannot be approved for 2020.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only an annual non-refundable fee of $25 is payable directly to most participating fitness facilities with some exceptions. Payment requests should be submitted after that month has passed, but within 90 days of the end of the calendar year.

The Plan's rules for coverage of gym benefits have not been met because payment was made to the facility on March 15, 2021 for the 2020 benefit allowance. Therefore, we decided that the Plan does not have to reimburse you for a gym membership for the 2020 benefit allowance.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve single-photon emission computed tomography (SPECT)
testing.
You asked the Plan to pre-approve SPECT testing. You say that you are appealing with supporting records. The
Plan denied your request. The Plan says this test is not medically necessary as the enrollee's entire spine has
already been imaged using magnetic resonance imaging.
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 SPECT testing. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has already undergone plain radiographic imaging and magnetic resonance imaging
of the entire spine with nothing to suggest acute fracture or infection in the bone. Nothing in the provided
records indicates what additional information could be obtained from a SPECT scan at this point. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SPECT testing have not been met. Therefore, we decided that the Plan does not
have to pre-approve single-photon emission computed tomography (SPECT) testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions of all your remaining teeth.
You asked the Plan to pre-approve extractions. You say that these services are necessary for you to improve your oral health and be in the best condition for your upcoming medical treatments. The Plan denied your request. The Plan says extractions are not covered by your dental benefit.
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, no dental extractions are among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental extractions of all your remaining teeth.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says your needs can be met at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records show that you do not require treatment by multiple therapies and an intensive rehabilitation therapy program. While the documentation does support a need for physical or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on February 16, 2021.

You asked the Plan to pay for an eye refraction. You say that you are a diabetic and need this service for eyeglasses. The Plan denied your request. The Plan says a refraction is covered when billed with a routine eye exam.

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 says that an eye refraction is only covered by the Plan when it is performed as part of a routine eye exam. 

We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, and therefore is not a covered 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 February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) provided May 4, 2021.

You asked the Plan to pay for the intraoral x-rays. You say that you were dissatisfied with the care provided and do not believe you should have to pay for it. The Plan denied your request. The Plan says you have exceeded frequency limits for this service and therefore it is 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. The Plan covers the intraoral x-rays once per calendar year. 

We looked at the file and Medicare rules. The Plan provided documentation showing that intraoral x-rays were covered on January 21, 2021. Based on this information, we determined that the Plan's frequency limit for the intraoral x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) provided May 4, 2021.

The Qualified Independent Contractor (QIC) read your letter and knows that you may have a quality of care concern. The QIC cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inhalation of nitrous oxide/analgesia, anxiolysis (D9230), gingival irrigation - per quadrant (D4921), and scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation (D4346).
You asked the Plan to pre-approve nitrous oxide/analgesia, gingival irrigation and scaling. You say that the services are medically necessary. The Plan denied your request. The Plan says these services are 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 pre-approve inhalation of nitrous oxide/analgesia, anxiolysis (D9230), gingival irrigation - per quadrant (D4921), and scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation (D4346).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device placement surgery.
You asked the Plan to pre-approve a Vertiflex Superion device placement surgery. You say that the requested
treatment is safe and effective, as supported by its clinical benefits to patients, continued medical professional
adoption, and strong clinical evidence with numerous peer-reviewed studies. The Plan denied your request. The
Plan says there are not enough studies to show that the use of the Vertiflex Superion device is better than
regular spine surgery for the enrollee's problem. The Plan says that there are not enough studies to show that
use of the Vertiflex Superion device will help in the enrollee's care.
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 a Vertiflex Superion device placement
surgery. Our reviewer says that a Vertiflex Superion device placement surgery is not considered medically
reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for spinal
stenosis, lumbar region, with neurogenic claudication.
The enrollee's past medical history was positive for hypertension, hyperlipidemia, diabetes mellitus type 2,
multiple sclerosis, obesity, diabetic peripheral neuropathy, gastroesophageal reflux disease, benign prostatic
hyperplasia, past cerebral infarct, osteoarthritis of the knee, and chronic neck pain. The enrollee's past surgical
history was positive for total knee arthroplasty, C3-C7 fusion. The enrollee's conservative treatments have
included medications, physical therapy, home exercise program, epidural steroid injection, and transcutaneous
electrical nerve stimulation (TENS). Large well-designed studies in the peer review scientific literature
comparing stand-alone use of Superion device to established surgical decompression are needed. Published
studies do not demonstrate any long-term health outcome advantage with the use of Superion as an alternative
to standard surgical treatment. Large population sufficiently powered randomized controlled trials that
demonstrate long-term health outcome advantages are 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 a Vertiflex Superion device placement surgery have not been met. Therefore,
we decided that the Plan does not have to pre-approve a Vertiflex Superion device placement surgery.