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

We decided that the Plan does not have to pay forthe eyeglasses purchased from "the vision center" on November 5, 2018.You asked the Plan to pay forthe eyeglasses. You say that you are very close to "the vision center" and you lost your only pair or prescription glasses and could not drive safely without glasses.The Plan denied your request. The Plan says enrollee's must receive vision services from an in-network vision provider.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 allows up to $150 allowance towards the purchase of contact lenses or eyeglasses every 2 years as long as you use a network vision provider. We looked at the file and the Plan's rules. "the vision center" is not in network with the plan. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met.Therefore, we decided that the Plan does not have to pay forthe eyeglasses purchased from "the vision center" on November 5, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says daily skilled therapy is not required.
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 pre-approve SNF services. Our physician reviewer found that from a nursing perspective, the enrollee has stable vital signs and his lungs are clear. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at supervision to contact guard assist with functional mobility. He required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 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 skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for breast tomosynthesis (77062) provided on September 4, 2019.You asked the Plan to pay for the breast tomosynthesis. You say that you would like reconsideration based on the recordssubmitted. The Plan denied your request. The Plan says procedure code 77062 has a status code of I which is 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 code 77062 is not supported in the medical record. Specifically, per the 2019 Physician Fee Schedule, 77062 has a status code of I. This means the 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for breast tomosynthesis (77062) provided on September 4, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided onAugust 9, 2019.You asked the Plan to pay forthe out-of-network services. You say that the services were provided to restore functional abilities.The Plan denied your request. The Plan says prior authorization is required for the services.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 in cases involving 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 forthe home health services provided on August 9, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on September 26, 2019.You asked the Plan to waive the copayment forthe office visit. You say that you were charged for a yearly free checkup.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20 for each Medicare-covered visit with an in-network primary care physician.You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that your hypercholesterolemia, osteopeniaand medicationswere discussed during the office visit. 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 forthe office visit provided on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on July 26, 2019.You asked the Plan to pay for the assembly and operation of a pump. You say that it takes a half hour to an hour to set up the Heart Lung Machine and the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service would be included in the part-A DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. 
We looked at the file and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of the assembly and operation of a pump have not been met. Specifically, payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on July 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from July 17, 2019 to July 20, 2019.You asked the Plan to pay for these drugs. The Plan denied your request. The Plan says that these drugs are not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe self-administered drugs provided from July 17, 2019 to July 20, 2019.Benefits for these drugs may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 18, 2019 by out of network provider.You asked the Plan to pay foroutpatient lab work. You say that you would like this appeal to be reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for the services in question.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 forthe medical services provided on July 18, 2019 by out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to approve continued skilled nursing facility (SNF) services beyond January 12, 2020.
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the continued services are 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 approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the submitted records show that you received oral medications and had stable vital signs. You received physical and occupational therapy in the SNF and need minimal assist with bed mobility and transfers. You are mobile in a wheelchair and need varied assistance with activities of daily living. You have no skilled nursing or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to approve continued skilled nursing facility (SNF) services beyond January 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hyperbaric oxygen therapy (99183) provided on May 1, 2019.You asked the Plan to pay forthe hyperbaric oxygen therapy. You say that the hyperbaric oxygen therapy provided was medically necessary.The Plan denied your request. The Plan says the hyperbaric oxygen therapy provided did not meet criteria.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 pay for the hyperbaric oxygen therapy. Our reviewer says that the hyperbaric oxygen therapy provided did not meet criteria. Our physician reviewer found the enrollee is with a submitted diagnosis of Lyme disease and history of invasive ductal carcinoma. A visit note from May 1, 2019 documents the enrollee presented for IV therapy. The note documents discussion of hot flashes the enrollee is currently receiving. Regarding the hyperbaric oxygen treatment, the documentation shows the enrollee had no issue with pressurization, tolerated treatment and decompressed without any adverse effects.Per Medicare criteria, the enrollee does not meet any criteria listed in the covered indications. Based upon the review of medical literature, the clinical value/effectiveness of this service has not been established in the peer-reviewed medical literature. The peer reviewed medical literature does not support the use of hyperbaric oxygen therapy for the treatment of Lyme disease or breast cancer. The review has determined that the enrollee does not have a covered condition per Medicare criteria for the provided hyperbaric oxygen 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 hyperbaric oxygen therapy have not been met.Therefore, we decided that the Plan does not have to pay forthe hyperbaric oxygen therapy (99183) provided on May 1, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided from May 9, 2019 through June 3, 2019.You asked the Plan to waive the copayment forSNF care. You say that you are not clear if you owe $850 or $100. You state you should not have to pay anything because the Plan allegedly misinformed you.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received twelve (12) dates SNF care from April 16, 2019 through April 27, 2019. You then received SNF care from May 9, 2019 through June 3, 2019. There were no copay charges for the first 20 days (April 16, 2019 through May 16, 2019). You were asked to pay a $50 copayment per day for SNF services provided on May 17, 2019, your 21st day through June 2, 2019. You were discharged on June 3, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $50 copayment required for days 21-100. Therefore, you are asked to pay a total of a $850 copayment for the SNF care. 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 forSNF care provided from May 9, 2019 through June 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fordiabetic supplies coded as A4253, A4259, A4256 and A4235 provided by "the provider" August 11, 2019 to October 30, 2019.You asked the Plan to pay forthe diabetic supplies. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so that the Medicare coverage criteria has been met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fordiabetic supplies coded as A4253, A4259, A4256 and A4235 provided by "the provider" August 11, 2019 to October 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for indwelling catheter; foley type, two-way latex with coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each (CPT Code A4338) provided to the enrollee on June 17, 2019.You asked the Plan to pay for the durable medical equipment (DME). You say that the service is medically necessary.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment (DME) have not been met. Review of the available clinical case notes and records presented for an appeal of DMEPOS equipment and/or supplies has been completed. The services are not authorized because they are a part-A benefit for skilled nursing facility (SNF) admissions and are included in the facility PPS payment. The facility received Medicare part-A skilled nursing facility payment and is responsible to provide all services and pay any and all vendors. After reassessing the entire situation, the result is that the initial denial is upheld and the service is not authorized. Medicare says, durable medical equipment and supplies are included in the skilled nursing facility payment.Therefore, we decided that the Plan does not have to pay for indwelling catheter; foley type, two-way latex with coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each (CPT Code A4338) provided to the enrollee on June 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 13,
2019.
You asked the Plan to waive the copayment for the office visit. You say that you received a wellness visit and
should not have a copayment for this visit. The Plan denied your request. The Plan says you have been charged
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 a $20
copayment for each in-network Medicare-covered visit with a PCP.
You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The medical record shows you were
also seen for a recheck of hyperlipidemia and hypertension in addition to the wellness visit.
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 office visit provided by on September 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the cardiac ablation procedure provided on August 29, 2019.You asked the Plan to reduce the copayment forthe cardiac ablation procedure. You say that the service was mistakenly billed as a diagnostic procedure rather than a surgical procedure. The Plan denied your request. The Plan says the claim has been adjusted to pay per the correct Evidence of Coverage to a membercost share of a $350 copayment.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 $350 copayment for each Medicare-covered outpatient hospital surgery. You have been asked to pay a $350 copayment for the cardiac ablation procedure. The cardiac ablation procedure 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 reduce the copayment forthe cardiac ablation procedure provided on August 29, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 11, 2019 by out of network provider.You asked the Plan to pay foran office visit. You say that you would like this claim reprocessed and approved.The Plan denied your request. The Plan says no prior authorization was obtained for the services in question.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 multiple in-network provider within 30 miles of the member'sresidence that could have rendered the services.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 payfor these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on October 11, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided to the enrollee on August 2,
2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there is no
documentation that the enrollee's condition warranted the need of TIVA by an anesthesia provider.
The Plan follows Medicare rules. Medicare rules say that monitored anesthesia care is only covered under
certain medical indications.
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 services provided. Our physician
reviewer found that the enrollee received transforaminal selective nerve root blocks. Epidural steroid injections
are typically performed in an ambulatory setting without sedation and without the services of an
anesthesiologist. There is nothing contained in the submitted documentation to warrant anesthesia services for
this procedure. The provided medical records do not support the use of anesthesia for this procedure.
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 services provided have not been met. Therefore, we decided that the Plan
does not have to pay for the anesthesia services provided to the enrollee on August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forradiation therapy provided from June 21, 2019 through August 30, 2019.You asked the Plan to waive the coinsurance forradiation therapy. You say that the cost of treatment was not disclosed. You say that your portion should be reduced.The Plan denied your request. The Plan says thecoinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each Medicare-covered radiation therapy service.You have been asked to pay a total of $1,666.35, which is 20% of the allowed amount for radiation therapy. Radiation therapy falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 forradiation therapy provided from June 21, 2019 through August 30, 2019.