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

We decided that the Plan does not have to pay for the eye refraction testing coded as 92015.

You asked the Plan to pay for the refraction testing. You say that you feel that this should be covered since it was medically necessary due to your diabetes. The Plan denied your request. The Plan says this service is not covered when provided during a medical eye exam with a Vision Care 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 refraction testing when provided during a routine vision exam with an Vision Care provider.

We looked at the file and the Plan's rules. We found that this refraction test was not provided by a Vision Care provider and was not provided during the course of a routine eye exam, but rather a medical eye exam. Based on this information, we decided that the Plan's rules for coverage of the refraction testing have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction testing coded as 92015.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network podiatry services.

You asked the Plan to pre-approve out-of-network podiatry services. You say that one of the doctors you were referred to is out, and others are too far to reach. You say that the prior authorization was not reviewed correctly. The Plan denied your request. The Plan says services are available in-network.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. 

The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services. Therefore, we decided that the Plan does not have to pre-approve out-of-network podiatry services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.
You asked the Plan to pre-approve the requested home health services. You say that you are having trouble bathing and taking care of other needs due to your conditions. The Plan denied your request. The Plan says the notes do not show you continue to have a medical problem that needs special care that only a nurse can do.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 requested home health services. Our reviewer says that the requested home health services do not meet the Medicare criteria for coverage. Our physician reviewer found the enrollee is a male who is requesting skilled nursing and home health aide visits as he is not able to care for himself for bathing. The most recent therapy documentation indicates the member is able to ambulate up to 150 feet without an assistive device. He has been instructed in a home exercise program. In this case, the documentation does not support that the member requires skilled nursing services to provide treatment that is medically necessary. The member does not require skilled nursing services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.
The requested home health services are 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 requested home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the tooth extraction (D7140) provided on December 16, 2020.
You asked the Plan to pay for the extraction. You say that "comprehensive dental" should cover at least part of the cost of tooth extractions. The Plan denied your request. The Plan says tooth extractions are not covered by Medicare or by the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, 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 tooth extraction (D7140) provided on December 16, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on November 25, 2020.
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges because you received the ultrasound directly after abnormal mammogram findings and were not informed of the cost. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $100 copayment for ultrasounds. You have been asked to pay a $100 copayment for an ultrasound. An ultrasound 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 copayment for an ultrasound provided on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services
provided on May 21, 2019.
You asked the Plan to pay for the evaluation and management service. You say that you did not receive proper
notice of the enrollee's benefit determination. You say that you depend on the facility for timely notification of
the enrollee's health insurance coverage. You also say that the provider rendered medically necessary services
to the enrollee in good faith. The Plan denied your request. The Plan says a claim must be received within 12
months or 1 calendar year from the date when the services were rendered. The Plan says that the claim was
received more than 12 months after the services were rendered.
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 evaluation and management service was not filed until December 10,
2020. 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 the psychiatric diagnostic evaluation with
medical services provided on May 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tepezza.
You asked the Plan to pre-approve Tepezza. You say that the medication is necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 Tepezza. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found the review has determined that the
documentation does not support that the Tepezza is medically reasonable and necessary or safe and effective
for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Tepezza have not been met. Therefore, we decided that the Plan does not have
to pre-approve Tepezza.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual routine physical exam (99397) provided October 22, 2020.
You asked the Plan to pay for the annual routine physical exam. You say that you are appealing the denial because you were experiencing pain in your chest, especially when you coughed, got up from sitting down or lying down. You were having pains in your shoulders and back and the pains were not getting better. The Plan denied your request. The Plan says the annual routine physical exam was previously provided on January 6, 2020 therefore, this benefit has been exhausted.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual routine physical exam (99397) provided October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee from September 4, 2020, to
September 9, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the current claim submitted does not have a valid diagnosis code. The current diagnosis
has a future effective date. The Plan states that for assistance with billing the correct diagnosis for the services
provided to our member, please review the ICD 10 Official Guidelines for Coding and Reporting. The Plan
states that they have not received a corrected claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due
to an issue with an inappropriate diagnosis code. Medicare rules for coverage of this service have not been met.
Therefore, we decided that the Plan does not have to pay for services provided to the enrollee from September
4, 2020, to September 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional home health physical therapy visits.
You asked the Plan to pre-approve 4 additional home health physical therapy visits. You say that these services are medically necessary. The Plan denied your request. The Plan says the enrollee has received more than double the recommended visits and the criteria for additional visits is not met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 4 additional home health physical therapy visits. Our reviewer says that the requested home health services are not medically necessary and reasonable. Our physician reviewer found the member is a 46-year-old female with a medical history including multiple sclerosis with chronic leg pain who has been treated with home health physical therapy. In this case, the documentation does not support that the member requires skilled services to provide treatment that is medically necessary. The member does not require skilled rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 additional home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional home health physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 28, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider.

You asked the Plan to pay for laboratory services. You say that advantage plans are required to pay out-of-network providers the Medicare rate. The Plan denied your request. The Plan says prior authorization was required but not obtained.

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 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 for laboratory services provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair (E1399) and a seat lift mechanism (E0627).
You asked the Plan to pre-approve a recliner chair and a seat lift mechanism. You say that a lift chair is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a lift chair.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical purpose. The rules also say that a seat lift mechanism is covered if all of the conditions listed are met. We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a recliner chair and seat lift mechanism have not been met. Specifically, a recliner chair is not durable medical equipment that is mainly used to serve a medical purpose. Additionally, the medical records provided do not indicate that the enrollee has severe arthritis of the hip or knee, or has a severe neuromuscular disease. Therefore, we decided that the Plan does not have to pre-approve a recliner chair (E1399) and a seat lift mechanism (E0627).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider.

You asked the Plan to waive the copayment for an emergency room visit. You say that you do not feel like you should be responsible for this copayment. 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 $110 copayment for emergency care.

You have been asked to pay a $110 copayment for an emergency room visit. The correct copayment has been applied to the services that were provided. An emergency room visit falls within the emergency care 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 an emergency room visit provided by a participating provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve self-administered drugs provided in a facility.

You asked the Plan to pre-approve self-administered drugs under Medicare Part B. You say that this claim should be covered by the Plan. The Plan denied your request. The Plan says payment for self-administered drugs must be submitted to your Medicare Part D carrier.

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 pre-approve self-administered drugs provided in a facility.

Benefits for 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..
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $20 copayment charged for specialist services.

You asked the Plan to waive this service. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says you had an eye procedure (Laser peripheral iridotomy coded as 66761). You had an office visit. The global period of service for billing for services related to this code is 10 days. You were billed $75 for your visit. The Plan states they paid $40.18 and billed you a $20 copay. Your Plan Evidence of Coverage states there is a $20 copay for each specialist's office visit. You were billed appropriately for a copay for an office visit outside the global period of services related to the procedure you underwent.

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 copayment for physician services. 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 $20 copayment charged for specialist services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram and laboratory services.

You asked the Plan to waive the copayment for the diagnostic mammogram and laboratory services. You say
that you are a cancer survivor and should be considered high risk. You say that all copayments should be $0.
The Plan denied your request. The Plan says the copayments 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 $75
copayment for all other diagnostic procedures and tests at all locations of service and a $40 copayment for lab
services only when provided in an outpatient hospital facility.

You have been asked to pay a total of $108.33 for the diagnostic mammogram and laboratory services.

The diagnostic mammogram and laboratory services fall within the "Outpatient diagnostic tests and therapeutic
services and supplies" benefit category. The records show a diagnostic mammogram was performed. 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 diagnostic mammogram and laboratory services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic and two retainer crowns.

You asked the Plan to pay for the pontic and retainer crowns. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services 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, 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 pontic and two retainer crowns.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound.

You asked the Plan to waive the copayment for an ultrasound. You say that you have only ever paid an office copayment in the past and disagree with the additional charges for the ultrasound. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $100 copayment for ultrasounds.

You have been asked to pay a $100 copayment for an ultrasound. An ultrasound 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 copayment for an ultrasound.