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

We decided that the Plan does not have to pre-approve a facet injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says several previous interventional pain procedures do not appear to have been beneficial.

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 pre-approve the injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has multi-level facet arthropathy worse at L4-L5.

The pain has been present for ore than three months. The record indicates that the enrollee has significant radicular symptoms. The elements of the coverage rule are not satisfied. 

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses (L1833) and suspension sleeves (L2397) provided November 12, 2020.

You asked the Plan to pay for the knee orthoses and suspension sleeves. You say that you would like these claims reprocessed and approved for medical necessity. The Plan denied your request. The Plan says the criteria for coverage were not met.

The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed 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 pay for the knee orthoses and suspension sleeves. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses and sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee orthoses and suspension sleeves have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses (L1833) and suspension sleeves (L2397) provided November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on October 4, 2019 by an out-ofnetwork
provider.
You asked the Plan to pay for the eyewear. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says the claim for services provided on October 4, 2019 was
processed correctly. The Plan states the claim was processed and paid by the In-Network level of
benefits and the plan cannot complete a refund, as the payment was sent.
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.
We looked at the file and the Plan's rules. The claim was processed and paid by the In-Network
level of benefits. The plan cannot complete a refund, as the payment was sent. If you have any
further questions please contact the provider. Therefore, we decided that the Plan does not have to pay for the
eyewear purchased on October 4, 2019 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on March 10, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, and an intraoral complete series of radiographic images. You say that this was your first visit to this provider, and you did not want to return to the previous provider you saw. The Plan denied your request. The Plan says the services are a covered benefit, but you have exceeded the frequency limit of one every 3 Plan 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. 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, and an intraoral complete series of radiographic images have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on May 6, 2019. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames and lenses on July 31, 2019.
You asked the Plan to pay for the frames and lenses. You say that you were told this provider was in-network.
The Plan denied your request. The Plan says that you must go to a 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 purchased from a network provider..
We looked at the file and the Plan's rules. The file indicates you did not purchase the frames and lenses from a network provider. Based on this information, we decided that the Plan's rules for coverage of the
frames and lenses have not been met. Therefore, we decided that the Plan does not have to pay for the frames
and lenses provided by Baystate Eye Care Opticial Shoppe on July 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a routine eye exam and eyeglasses provided on September 30, 2020.
You asked the Plan to waive the copayment for the routine eye exam and eyeglasses. The Plan denied your request. The Plan says per your Evidence of Coverage, you pay $15 for one annual routine eye exam and you have up to $150 benefit for reimbursement of eyewear.
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. We looked at the file and the Plan's rules. Therefore, we decided that the Plan does not have to waive the copayment for a routine eye exam and eyeglasses provided on September 30, 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 LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.

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 LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 11, 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 March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for EEG's provided from March 8, 2021, to March 10, 2021.

You asked the Plan to waive the copayments for EEG's. You say that you feel that you are being charged for services you did not receive. 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 $110 copayment for basic radiological services provided at an outpatient facility. 

The medical records show that you received EEG's at outpatient hospital facilities from March 8, 2021, to March 10, 2021, for a total of 3 services. Therefore, you are responsible to pay a $105 copayment per each service. The total amount you owe is: $315. 

You have been asked to pay the total copayment amount of $315 for EEG's. EEG's fall within the outpatient hospital 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 copayments for EEG's provided from March 8, 2021, to March 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the patient does not meet criteria for coverage of SNF therapy services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5257) received on April 13, 2021.

You asked the Plan to pay for hearing aids. You say that you want the Plan to reimburse you for the items. The Plan denied your request. The Plan says a bank statement is not an acceptable proof of payment.

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.

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, sufficient documentation was not submitted to determine whether payment is due and the amount of payment. A bank statement is not an acceptable proof of payment. Therefore, we decided that the Plan does not have to pay for hearing aids (V5257) received on April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120), topical application of fluoride varnish (D1206) and periodontal maintenance (D4910) provided March 30, 2021.

You asked the Plan to pay for the periodic oral exam, fluoride varnish and periodontal maintenance. You say that the provider told you that they accepted your insurance. The Plan denied your request. The Plan says the provider is out-of-network and therefore the services are not covered. Additionally, fluoride varnish and periodontal maintenance are not covered under your benefits. The Plan also says they are reviewing your other issues separately.

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. The Plan covers the periodic oral exam when provided in-network. Out-of-network you pay 100% of the cost.

We looked at the file and Medicare rules. In this case the services were provided out-of-network. Therefore, you are responsible for 100% of the cost for the periodic oral exam. Though the Plan offers a dental benefit in excess of Medicare coverage, the fluoride varnish and periodontal maintenance are not among those services covered. Therefore, we decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120), topical application of fluoride varnish (D1206) and periodontal maintenance (D4910) provided March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an impression casting of foot (S0395) performed on January 6, 2021.
You asked the Plan to pay for an impression casting of foot. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the service at issue is not a Medicare benefit.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S0395 has a status indicator of "I" on the Physician Fee Schedule. This means that it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of an impression casting of foot have not been met. Therefore, we decided that the Plan does not have to pay for an impression casting of foot (S0395) performed on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on April
21, 2021.

You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the
charges because your primary care physician would not see you due to Coronavirus. You state that you cannot
afford the charges. 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 $65
copayment for urgently needed services.

You have been asked to pay a $65 copayment for urgently needed services. Urgently needed services fall
within the urgently needed 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
urgently needed services provided on April 21, 2021.

We note your complaint that your primary care physician would not see you due to the Coronavirus. Your
complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on March 12, 2021.

You asked the Plan to waive the copayment for emergency care. You say that you are unhappy with the care the enrollee received and you feel that they should not be responsible to pay a copayment. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment for emergency care. 

The enrollee has been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on March 12, 2021.

Your quality of care concerns have been handled separately by the health plan. Medicare does not permit the Qualified Independent Contractor to make a decision on this type of complaint.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 29, 2021 by an out-of-network provider.

You asked the Plan to pay for subsequent nursing facility care (99309). You say that the services were medically necessary and provided prior to obtaining authorization to avoid delay in care. The Plan denied your request. The Plan says you did not request prior authorization.

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 service 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 the service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 29, 2021 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture and infrared therapy provided by an acupuncturist on January 13, 2021.

You asked the Plan to pay for the acupuncture and infrared therapy. You say that acupuncture medical records should be reviewed for payment. The Plan denied your request. The Plan says a licensed acupuncture is a non-covered provider type.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the acupuncture and infrared therapy were not provided by a legally qualified physician. Therefore, we decided that the Plan does not have to pay for acupuncture and infrared therapy provided by an acupuncturist on January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided by an opt-out-provider on November 11, 2020.

You asked the Plan to pay for the dental services. You say that the letter from the Plan states you can go to any dentist in the United states and they do not have to be part of the dental network. You say that you are appealing the denial based on the letter that was sent. The Plan denied your request. The Plan says no Medicare payment may be made to a beneficiary for services provided by a physician or practitioner who has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental services provided by an opt-out-provider on November 11, 2020.