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

We decided that the Plan does not have to pay for fitting of spectacles, except for aphakia (92341) refraction services (92015) frames (V2020) Sphere, bifocal (V2201) provided December 3, 2020.
You asked the Plan to pay for the vision services. You say that a provider performing services in a nursing home facility is not responsible to obtain authorization. You believe it is imperative that the Plan reimburse the doctor for all services rendered. The Plan denied your request. The Plan says enrollee's must receive their vision 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 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 vision services when rendered by an in-network vision provider. We looked at the file and the Plan's rules. 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. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for fitting of spectacles, except for aphakia (92341) refraction services (92015) frames (V2020) Sphere, bifocal (V2201) provided December 3, 2020.
Appeal type: Testing
Decision: Unfavorable

decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) provided on April 19, 2021.
You asked the Plan to pay for a PET scan. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with an inappropriate diagnosis.
The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate diagnosis code. We looked at the file and Medicare rules. The billed diagnosis code, R70.0, is not listed as an appropriate code. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) provided on April 19, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the $25 copayments charged for outpatient mental health care provided from November 16, 2020 to December 28, 2020.
You asked the Plan to waive these copayments. You say that no one told you there would be a copayment to see a psychiatrist. The Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement.
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 $25 copayment for each outpatient mental health visit. 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 $25 copayments charged for outpatient mental health care provided from November 16, 2020 to December 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided April 26, 2021.
You asked the Plan to waive the copayment for the ambulance transport. You say that you thought there would be no copayment since you had prior authorization for the service. The Plan denied your request. The Plan says the copayment was 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 a $300 copayment for Medicare-covered ambulance transport (one-way). You have been asked to pay a $300 copayment for the ambulance transport. This transport falls within the Ambulance services benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement (D4355) services provided April 20, 2021.
You asked the Plan to pay for the dental services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says this service is not covered under the Plan 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. Services not listed is not covered. 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 the full mouth debridement (D4355) services provided April 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a trigger point injection provided by a participating provider on May 6, 2019, to February 3, 2021.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with these copayments. The Plan denied your request. The Plan says the correct copayments have 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 $245 copayment for outpatient surgery/in-network. You have been asked to pay a $245 copayment for an outpatient surgery.
Total Amount Being Asked to Pay: $33.42 + $245 + $34.27 + $40 + $34.27 + $34.27 + $34.27 + $245 = $626.23
The correct copayments have been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/in-network 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 trigger point injection provided by a participating provider on May 6, 2019, to February 3, 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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 there is no documentation provided indicating medical necessity for the admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital and does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 the LTACH services have not been met. Specifically, medically necessary services are being obtained at the enrollee's current level of care. This means admission into a LTACH is not medically necessary.
Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the trigger point injections (20552) provided on September
25, 2020.
You asked the Plan to pay for the trigger point injections. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says there is not sufficient documentation to
determine the medical necessity of the trigger point injections.
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 trigger point injections. Our reviewer
says that there was no documentation of a detailed history and thorough physical examination. There was no
described dermatome or radicular pain pattern. There was no documented trial of activity modification, home
exercises, non-steroidal anti-inflammatory drugs, physical therapy, or spinal manipulation for six weeks or
longer. There is no significant decrease in range of motion, strength or stability sufficient to interfere with
activities of daily living or having significant impact on school or job performance. There was no documented
comprehensive treatment plan with milestones and goals outlined. There was no documented absence of other
serious pathology, i.e. acute fracture, dislocation, ligament rupture, tumor, arthritis, or infection. Our physician
reviewer found since history and physical examination were not documented and the patient had not failed
conservative therapy, the requested trigger point injections were not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the trigger point injections have not been met. Therefore, we decided that the
Plan does not have to pay for the trigger point injections (20552) provided on September 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 1, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the drug testing services provided on December 1, 2020.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 there is no documentation provided indicating medical necessity for the admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital and does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving 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 the LTACH services have not been met. Specifically, medically necessary services are being obtained at the enrollee's current level of care. This means admission into an LTACH is not medicaly necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
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 an IRF is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for an IRF are not met. The enrollee's ongoing therapy 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 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. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on April 12, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that the doctor had to do a complete dental exam as he had not seen you before. You say that it is unfair for the Plan to deny this claim as the visit was required due to their decision to deny the original claim. The Plan denied your request. The Plan says you are only allowed one comprehensive oral evaluation every three calendar years.
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, a comprehensive oral evaluation is only covered once every three years. The Plan paid for a comprehensive oral evaluation provided on April 29, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on April 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (C8928) provided on March 1, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the number of units billed exceeds the MUE value.
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 code C8928 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (C8928) provided on March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and intraoral x-rays provided on March 1, 2021.
You asked the Plan to pay for the limited oral evaluation and intraoral x-rays. You say that your dentist retired and sent your records to this doctor. You say that you have coverage for an evaluation and x-rays, and you want to know why a covered service wasn't paid. The Plan denied your request. The Plan says intraoral x-rays are only covered once per calendar year and the limited oral evaluation 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, only one intraoral x-ray is covered from an out-of-network provide per year. The Plan paid for one intraoral x-ray provided on March 1, 2021, which exhausted your benefit. The additional intraoral x-ray and limited oral evaluation are not covered benefits. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation and intraoral x-rays provided on March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services provided on May 4, 2021 by an out-ofnetwork
provider.
You asked the Plan to pay for debridement, muscle and/or fascia (includes epidermis, dermis, and
subcutaneous tissue, if performed); first 20 sq cm or less (11043). You say that the services were medically
necessary. The Plan denied your request. The Plan says you did not request prior authorization as required.
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 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 for wound care services provided on
May 4, 2021 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 implants (D6010) provided on January 18, 2021.
You asked the Plan to pay for the dental services. You say that you were misinformed about the coverage when you signed up with this plan. You also say that when you signed up for the plan, the information you were given did not include anything about stipulations to implant coverage, including no waiting period. The Plan denied your request. The Plan says implants are not covered for teeth that were extracted prior to your effective date. The Plan also says that the only exception to this is if you have been enrolled in the plan for 24 continuous months.
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 and implants are listed as covered services, they are not covered for teeth that were extracted prior to your effective date. The record shows that you signed up for this plan, effective January 1, 2021. The record also shows that teeth # 4 and 14 have been missing for approximately 1 year. Therefore, we decided that the Plan does not have to pay for the 2 implants (D6010) provided on January 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator for the enrollee. You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records provided by the doctor do not show that the blood gas levels meet the criteria.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. To qualify for home oxygen, the patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. 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 concentrator. Our reviewer says that the requested item is not medically reasonable or necessary. Our physician reviewer found the medical records do not show evidence of hypoxemia. 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 concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator for the enrollee.