Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair (K0825).

You asked the Plan to pre-approve a group 2 power wheelchair (K0825). You say that the requested group 2 power wheelchair (K0825) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested group 2 power wheelchair (K0825).

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 group 2 power wheelchair (K0825). Our reviewer says that the enrollee does not meet criteria for the requested group 2 power wheelchair (K0825). Our physician reviewer found the enrollee does have a personal mobility deficit but does not appear to significantly impair participation in mobility related activities of daily living (MRADLs). The enrollee is independent in MRADLs and uses a cane.

There is no evidence that the enrollee is completely unable to use an appropriately fitted walker, or manual wheelchair or even needs this to complete MRADLs in the home. While he may have the cognitive ability to safely operate a PMD in the home the documentation does not indicate that the home has the appropriate maneuvering space, or support that this requested PMD will significantly improve the enrollee's ability to participate in MRADLs in the home. 

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 group 2 power wheelchair (K0825) have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair (K0825).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 17, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.
The ambulance company did not provide transport services on October 17, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (20610, 99213, J1030) provided on July 15, 2020.

You asked the Plan to pay for the office services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available. The services were not emergent or pre-authorized.

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 an office visit (20610, 99213, J1030) provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on March 25, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were not aware that the dentist had filed the other clam as an emergency dental service. The Plan denied your request. The Plan says benefits for this service are limited to one time per calendar year.
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, emergency diagnostic exam is limited to 1 per year. The record shows that you received a problem focused limited oral evaluation on February 19, 2021 and your emergency diagnostic exam benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on January 7, 2021.

You asked the Plan to pay for the eye refraction. You say that you saw this provider for a second opinion on a medical condition and they ran several different tests. You were dissatisfied with the care provided and do not understand why you are being charged for a refraction, when you have had this service covered before at no cost to you. The Plan denied your request. 

The Plan says this claim was processed correctly. Refractions are not covered by Medicare and are only covered by the supplemental benefit as part of a routine, non-medical visit. Refractions are not eligible for reimbursement when provided as part of a medical visit.

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. Medicare does not cover eye refractions. The Plan covers refractions under the supplemental benefit when it is part of a routine vision exam for prescription eyewear and provided by an optical network provider. 

We looked at the file and the Plan's rules. This refraction was provided as part of a medical exam and not as part of a routine visit for prescription eyewear. The record includes a copy of a form with your signature acknowledging that this service is not covered by Medicare and most Plans. The Plan has also indicated that this provider is part of the Plan's medical network but is not part of the Plan's routine optical network. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on January 7, 2021.

Your complaint about the care provided by a Plan-contracted provider 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits you from December 23, 2020, to March 24, 2021.
You asked the Plan to waive the copayments for the specialist visits. You say that you were told that there would be no copayment for this service. The Plan denied your request. The Plan says you were charged these copayments 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 $5 copayment for specialist visits.
You have been asked to pay a $5 copayment for the specialist visits. 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 copayments for specialist visits you had from December 23, 2020, to March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the cardiology visit and the transthoracic echocardiography (TTE) you received on January 22, 2021.
You asked the Plan to waive the cost sharing for the cardiology visit and the TTE. You say that you cannot afford this cost sharing. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that for the cardiology visit, the allowed amount for this service ($41.49) is less than your copayment obligation, so you are responsible for the full allowed amount for this service.
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 $45 copayment for specialist services and a $110 copayment for diagnostic radiology services.
You have been asked to pay a $45 copayment for the cardiology visit and a $110 copayment for the TTE. The cardiology visit falls within the specialist services benefit category and the TTE falls within the diagnostic radiology 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 cost sharing for the cardiology visit and the transthoracic echocardiography (TTE) you received on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99232) provided February 21, 2020.
You asked the Plan to pay for the hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the hospital care was not filed until February 23, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for hospital care (99232) provided February 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) received February 24, 2021.
You asked the Plan to pay for the limited oral evaluation - problem focused. You say that you have a $2,000 per year dental benefit and you should not have to pay for this service. The Plan denied your request. The Plan says the $2,000 annual benefit allowance is only applicable towards covered services. The requested service is not covered under your supplemental 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 the limited oral evaluation - problem focused (D0140) received February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (90837) provided on February 8, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were network providers available.
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 therapy services (90837) provided on February 8, 2021 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is needed. The Plan denied your request. The Plan says the benefit has been exhausted.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way transportation trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the sinus endoscopy surgical services you received at an outpatient hospital facility from June 11, 2019, to August 20, 2019.

You asked the Plan to waive the copayments for the outpatient surgical services. You say that you should not have to pay these copayments because of the extreme delay in the billing. The Plan denied your request. The Plan says you have been charged these copayments 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 $150 for each outpatient surgery services in an outpatient hospital facility. You have been asked to pay a $150 for each of the outpatient surgical services. 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 copayments for the sinus endoscopy surgical services you received at an outpatient hospital facility from June 11, 2019, to August 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic digital breast tomosynthesis represented by
code G0279 provided on March 12, 2021.

You asked the Plan to pay for code G0279. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file, the Plan's contract and Medicare rules. The file shows that the Plan had previously paid
for code G0279 on a different claim with the same enrollee, date of service, and provider. Therefore, we
decided that the Plan does not have to pay for the diagnostic digital breast tomosynthesis represented by code
G0279 provided on March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 4) provided on March 8, 2021.

You asked the Plan to pay for the gingival irrigation. You say that when you signed up for the plan, you were advised that dental coverage was included in your insurance. The Plan denied your request. The Plan says gingival irrigation is not listed as a covered service.

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, gingival irrigation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921 x 4) provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing (D4342 x 3) provided on February 2, 2021.

You asked the Plan to pay for the dental services. You say that this is a medical claim that the plan needs to pay. You say that the Plan paid $190 out of $1,569. You also say when this medical condition goes untreated it can cause gum disease which can go to heart disease. The Plan denied your request. The Plan says periodontal scaling and root planing is specifically related to treatment of periodontal issues that are neither routine nor preventive.

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 periodontal scaling and root planing for 3 quadrants are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the scaling and root planing (D4342 x 3) provided on February 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo for the enrollee.

You asked the Plan to pre-approve Opdivo. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that this is not being prescribed for a medically-accepted indication.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Opdivo. Our reviewer says that Opdivo
is not medically reasonable and necessary for the enrollee. Opdivo is not FDA-approved for the enrollee's
diagnosis. Opdivo is not supported by one of the major drug compendia or by clinical research that appears in a
CMS-approved medical journal. The use of Opdivo is not listed as not indicated, not supported or not
recommended in any of the compendia Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for Opdivo.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo for the enrollee.
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 you need IRF care. The Plan denied your request.
The Plan says rules for IRF care have not been met.

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 you were admitted for sepsis. Medical conditions are stable. There are no
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program.

Although you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, it is not a reasonable expectation that this patient 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 maxillary immediate denture (D5130), four simple
extractions (D7140 x4), and four surgical extractions (D7210 x4) provided on September 24, 2020 by an OON
provider.

You asked the Plan to pay for the maxillary immediate denture, simple extractions, and surgical extractions.
You say that you do not understand the decision about the OON provider. You also say that you have financial
hesitation due to COVID-19. The Plan denied your request. The Plan says services performed by an OON
provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you
did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

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 responsible for 100% of the cost for dental services received OON. Therefore, we decided that the Plan does not have to pay for the maxillary immediate denture (D5130), four simple extractions (D7140 x4), and four surgical extractions (D7210 x4) provided on September 24, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular risk screening (81185, 81401, 81404, 81405, 81406, 81479) provided on October 26, 2020.

You asked the Plan to pay for a hereditary cardiovascular risk screening. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. 

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular risk screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular risk screening (81185, 81401, 81404, 81405, 81406, 81479) provided on October 26, 2020.