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

We decided that the Plan does not have to pay for hearing aids (V5261) received on March 1, 2021.
You asked the Plan to pay for hearing aids. You say that you thought the item would be partially covered by the Plan. The Plan denied your request. The Plan says the items were received from a non-participating provider and are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when you utilize the Plan's designated vendor. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Specifically, the items were received from an out-of-network vendor and are not covered. Therefore, we decided that the Plan does not have to pay for hearing aids (V5261) received on March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an occlusal guard (D9944) received on March 9, 2021.

You asked the Plan to pay for an occlusal guard. You say that this item is necessary. The Plan denied your request. The Plan says the item at issue is not a covered 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an occlusal guard (D9944) received on March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781), and deluxe frames (V2025) received on November 22, 2020.

You asked the Plan to pay for progressive lenses, and deluxe frames. You say that you had to use an online provider due to COVID-19. The Plan denied your request. The Plan says you are not covered for this when services are rendered by an out-of-network 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 you use an in-network provider. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of progressive lenses, and deluxe frames have not been met. Specifically, services were provided by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781), and deluxe frames (V2025) received on November 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two additional dental extractions provided on December 9, 2020.

You asked the Plan to pay for two additional dental extractions. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says you are only covered for two
dental extractions per calendar year under the Plan's supplemental dental benefit. The Plan says that they paid
for two of the dental extractions you received on December 9, 2020 and the remaining are 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, you are only covered for up to two
dental extractions per calendar year. The file shows that you received multiple dental extractions on December
9, 2020 and the Plan paid for two of them. Therefore, we decided that the Plan does not have to pay for two
additional dental extractions provided on December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power seat elevation (CPT code E2300), attendant control, proportional, including all related electronics and fixed mounting hardware (CPT code E2331) and bag hooks (CPT code K0108), for the enrollee.

You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your request. The Plan says the items are not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

Medicare Guidance says the seat elevator and bag hooks are not medical in nature. The rules say that if an attendant control (E2331) is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. Therefore, the attendant control is not medically needed for a wheelchair with patient control. Therefore, we decided that the Plan does not have to pre-approve power seat elevation (CPT code E2300), attendant control, proportional, including all related electronics and fixed mounting hardware (CPT code E2331) and bag hooks (CPT code K0108), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 13, 2020, billed
with codes 99215-25 and 99358.

You asked the Plan to pay for the medical services. You say that this was billed correctly and should be paid.
The Plan denied your request. The Plan says these services are not supported as 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 99358 is Prolonged evaluation and management service
before and/or after direct patient care; first hour. Code 99215-25 is reported along with the paid code 32555.
32555 is a minor/endoscopic procedure meaning that separate payment can only be made for 99215 if a
separately identifiable service was provided.

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 medical services. Our reviewer says that
the codes at issue are not supported by the medical records. Our physician reviewer found the documentation
does not show that a separate, identifiable evaluation and management service was provided along with the
minor procedure on this date of service. The prolonged evaluation and management service described by 99348
cannot be covered as the primary service is also not covered. In addition, there is no documentation of
significant time being spent after direct patient care to allow payment of this service.

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 medical services have not been met. Therefore, we decided that the Plan
does not have to pay for the medical services provided on October 13, 2020, billed with codes 99215-25 and
99358.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the injections provided on February 19, 2021.
You asked the Plan to reduce the copayment for Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch (64450). You say that you cannot afford this copayment every month. The Plan denied your request. The Plan says you were charged this copayment 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 a $450 copayment for Outpatient Hospital Services, Surgery Services. You have been asked to pay a $450 copayment for Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch (64450). The injections (64450) fall within the Outpatient Hospital Services,
Surgery 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 reduce the copayment for the injections provided on February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), gingival irrigation (D4921 x2), scaling in the presence of generalized moderate or severe gingival inflammation (D4346), and an upper partial denture (D5213) provided on February 10, 2021.

You asked the Plan to pay for a comprehensive oral evaluation, gingival irrigation, scaling in the presence of generalized moderate or severe gingival inflammation, and an upper partial denture. You say that you shouldn't have to pay anything. The Plan denied your request. The Plan says the comprehensive oral evaluation is a covered benefit, but you have exceeded the frequency limit of one every 3 Plan years. The Plan paid at the in-network rate of 30% for scaling in the presence of generalized moderate or severe gingival inflammation. An upper partial denture and gingival irrigation are not covered 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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, gingival irrigation, scaling in the presence of generalized moderate or severe gingival inflammation, and an upper partial denture have not been met. Specifically, the record shows that you had exceeded the frequency limit for the comprehensive oral evaluation prior to this service on February 8, 2021. The Plan paid for scaling in the presence of generalized moderate or severe gingival inflammation at the in-network rate of 30%. Additionally, an upper partial denture and gingival irrigation are not covered benefits. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), gingival irrigation (D4921 x2), scaling in the presence of generalized moderate or severe gingival inflammation (D4346), and an upper partial denture (D5213) provided on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a radiology office visit provided on April 23, 2021.

You asked the Plan to waive the copayment for specialist visit. You say that you have never had to pay a copayment for your yearly mammogram. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $40 copayment for specialist visit. This copayment was applied to the specialist office visit which you received in addition to the mammography services, for which you have not been charged any cost-sharing. 

You have been asked to pay $40 copayment for specialist visit. Specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 radiology office visit provided on April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services and an ultrasound provided by a participating provider on February 22, 2021.

You asked the Plan to waive the copayment for vision services and an ultrasound. You say that you do not agree with these charges. 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 $35 copayment and a $100 copayment for visions care and outpatient diagnostic tests/diagnostic tests.

You have been asked to pay a $35 copayment for vision services and $48.40, which is less than your copayment amount of $100 for an ultrasound. The total amount you are being asked to pay is $83.40 ($35 + $48.40 = $83.40). Vision service falls within the visions care benefit category and an ultrasound falls within the outpatient diagnostic tests/diagnostic tests 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 vision services and an ultrasound provided by a participating provider on February 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on January 25, 2021.

You asked the Plan to pay for the CxBladder testing. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says this testing is not a Medicare covered benefit.

The Plan must follow Medicare rules. Medicare rules say that non-coverage of the CxBladder assay coded as 0012M has been reaffirmed. 

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, the CxBladder coded as 0012M is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dexcom G6 CGM (CPT code K0554), for the enrollee.

You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

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. There is no documentation that the enrollee is insulin-treated with multiple daily injections (MDI) of insulin or a continuous subcutaneous insulin infusion (CSII) pump, and that the enrollee's insulin treatment regimen requires frequent adjustment by the enrollee on the basis of therapeutic BGM testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the Dexcom G6 CGM (CPT code K0554), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on May 12, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you were under the impression that this service would be covered. The Plan denied your request. The Plan says the benefit maximum has been met. The Plan also says that no misinformation was provided to you regarding your dental coverage.

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, comprehensive oral exams are limited to once every 36 months. The record shows that you received a comprehensive oral evaluation on November 15, 2018, and your comprehensive oral exams benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider on September 21, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.

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 services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on September 21, 2020.
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 requested on July 1, 2021.

You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says therapy and care can safely and effectively be delivered in a skilled nursing facility once you are medically cleared to transition from the acute facility.

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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 requested on July 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets and/or exceeds the requirements for LTACH level of care. The Plan denied your request. The Plan says the records do not show that is it medically necessary for the enrollee to be in an LTACH in place of an acute care hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on January 26, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgeon
services are not payable for this procedure.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1,
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current
Procedural Terminology (CPT) code 25606. The Medicare Fee Schedule Database contains a surgical indicator
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the
services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon
services provided on January 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on March 19, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you feel this service should be covered
because you did not know it would be billed as a non-covered service. The Plan denied your request. The Plan
says self-administered drugs are not covered.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 for the self-administered drugs
provided on March 19, 2021.

Benefits for the self-administered 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.