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

We decided that the Plan has to provide additional reimbursement for the eye wear purchased on November 26, 2019.
You asked the Plan to provide additional reimbursement for the eyewear. You say that you need assistance paying for the eye wear. The Plan denied your request. The Plan says that that they paid the $300 allowed per year.
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 $300 toward eye wear provided by a participating provider. We looked at the file and the Plan's rules. The file indicates the plan paid $180 towards your eye wear purchase. The file indicates you visited a participating provider and that the Plan did not pay the total $300 allowance. Based on this information, we decided that the Plan's rules for coverage of the eyewear have been met. Therefore, we decided that the Plan has to provide additional reimbursement up to the $300 allowance for the eye wear purchased on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames and lenses purchased on November 6, 2019 from an out-of-network provider.
You asked the Plan to pay for the frames and lenses. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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. Based on this information, we decided that the Plan's rules for coverage of the frames and lenses have not been met. The provider is not in-network and your EOC clearly states, vision benefits are through the plan. You pay any amount over $100 retail price for frames and lens package. You have a choice of: eyeglasses or contact lenses and fitting at a network optical provider
(per calendar year). Therefore, we decided that the Plan does not have to pay for the frames and lenses purchased on November 6, 2019 from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92014) provided on November 11, 2019.
You asked the Plan to pay for the eye exam. You say that you would like reconsideration as you were not
aware that this provider was not in the Plan's network. The Plan denied your request. The Plan says treatment
of a medical condition of the eye by a provider that is not in the plans network is not a covered benefit.
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 obtained in the plans network.
We looked at the file and the Plan's rules. Per the EOC, you must use a provider in the plans
network. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not
been met. Therefore, we decided that the Plan does not have to pay for an eye exam (92014) provided on
November 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full cost of an eye exam (92014) and refraction (92015) provided on October 10, 2019.
You asked the Plan to pay the full cost of an eye exam and refraction. You say that it was not clear you needed to use a plan provider. The Plan denied your request. The Plan says this processed correctly.
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 out-of-network routine eye exams up to $75. You are responsible for any cost above $75. We looked at the file and the Plan's rules. The provider you received these services from is not in-network provider. Based on this information, you are responsible for charges above $75 for this service. Therefore, we decided that the Plan does not have to pay the full cost of an eye exam (92014) and refraction (92015) provided on October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power wheelchair (K0800) provided March 29, 2021.

You asked the Plan to pay for the power wheelchair. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the records do not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code K0800 is power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds. 

We find that an additional unit of CPT code K080 is not supported in the medical record. Specifically, there is no evidence that more than 1 power operated vehicle is being provided to the enrollee. In this case, the Plan has agreed to payment of 1 power operated vehicle but has denied the second as a duplicate claim. Based on this information, we decided that Medicare rules for coverage of the power wheelchair have not been met. Therefore, we decided that the Plan does not have to pay for the power wheelchair (K0800) provided March 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the aflibercept injection provided on February 9, 2021 and March 9, 2021.

You asked the Plan to waive the coinsurance for the aflibercept injection. You say that you obtained prior authorization prior to the procedure and you were only advised of the $45 copayment. You say that you were informed the medication is covered 100% without member responsibility. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare covered Part B drugs dispensed at a retail pharmacy, mail order pharmacy, physician office and outpatient facility. 

You have been asked to pay a total of $737.40 for the aflibercept injections.

The aflibercept injections fall within the "Medicare Part B prescription drugs" 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 coinsurance for the aflibercept injection provided on February 9, 2021 and March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration, extractions and bone replacement grafts provided on February 3, 2021.

You asked the Plan to pay for the guided tissue regeneration, extractions and bone replacement grafts. You say that your insurance says you get reimbursed $750 for 2021. You say that Medicare did not pay this invoice and the mistake should be corrected. The Plan denied your request. The Plan says payment will not be made 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 a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration, extractions and bone replacement grafts provided on February 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for outpatient surgery services and laboratory services in an outpatient hospital setting provided on March 6, 2020.

You asked the Plan to waive the cost sharing for outpatient surgery services and laboratory services. You say that the claim for services you assumed had been paid in full should not have been adjusted a year later. The Plan denied your request. The Plan says the correct cost sharing was 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 20% coinsurance for surgery performed at an outpatient hospital facility and a $40 copayment for laboratory services provided in an outpatient hospital facility. You have been asked to pay $740.13, or 20% of the Medicare-allowed charge of $3,700.70, for outpatient surgery services. Outpatient surgery services fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. 

You have also been asked to pay a $40 copayment for laboratory services provided in an outpatient hospital facility. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amounts 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 outpatient surgery services and laboratory services in an outpatient hospital setting provided on March 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the advance care planning services coded 99497 and the new or established patient initial hospital inpatient care services coded 99223 provided on October 29, 2020.

You asked the Plan to pay for the advance care planning services and the new or established patient initial hospital inpatient care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 codes 99497 and 99223 are not supported in the medical record. Specifically, medical records were not provided for review in this case. The record shows that the Plan made multiple attempts to secure medical records, without success. Without medical records, we cannot determine if Medicare criteria are met in this case. Based on this information, we decided that Medicare rules for coverage of the advance care planning services and the new or established patient initial hospital inpatient care services have not been met. Therefore, we decided that the Plan does not have to pay for the advance care planning services coded 99497 and the new or established patient initial hospital inpatient care services coded 99223 provided on October 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) testing.

You asked the Plan to pre-approve TTE testing. You say that this procedure is necessary for the enrollee's health. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee does not meet the criteria for TTE.

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 TTE testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had mild aortic insufficiency noted on an echocardiogram done in 2019. There were no symptoms reported then and ventricular systolic function was normal. She currently reports no symptoms of dyspnea, edema, or orthopnea and her exam is normal and without a murmur. In the absence of symptoms or signs of congestive failure, a changing murmur on exam, or other new symptoms. Patients with mild aortic insufficiency and preserved left ventricle function on echocardiography should generally be followed up with repeat echocardiography at 3 to 5 year intervals to reassess the significance of the aortic regurgitation. As it has only been 2 years since the last echocardiogram, and in the absence of new symptoms or signs of cardiovascular disease, repeat echocardiography would not be considered medically necessary 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 TTE testing have not been met. Therefore, we decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on February 2, 2021.

You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. 

Review of the file shows that the plan uses Local Coverage Determination (LCD) L36523 to support their denial. However, LCD L36523 is not valid for the provider's billing state of Pennsylvania. Therefore, we are unable to use LCD L36523 to substantiate our decision. 

While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on February 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (G0483) provided on January 20, 2021.

You asked the Plan to pay for the laboratory services. 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 and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (G0483) provided on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on April 1, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for skilled nursing services. You say that you would like this reprocessed and paid due to medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 items/services at issue in this appeal. 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 skilled nursing services provided on April 1, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-sterile gloves (A4927).

You asked the Plan to pre-approve non-sterile gloves. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve non-sterile gloves (A4927).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the external defibrillator garment provided on February 16, 2021 to February 21, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that you received a referral from the medical group. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the external defibrillator garment provided on February 16, 2021 to February 21, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 16, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 items/services at issue in this appeal. 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 an office visit provided on January 16, 2020 by an out-of-network (OON) 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 February 18, 2021.

You asked the Plan to pay for a comprehensive oral evaluation, and an intraoral complete series of radiographic images. You say that you were not aware of frequency limitations and the provider told you the services would be covered. The Plan denied your request. The Plan says the services are covered benefits, 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 March 15, 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 February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on January 15, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and paid due to medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available for these services.

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 items/services at issue in this appeal. 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 specialist services provided on January 15, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating hospital facility on February 25, 2021.

You asked the Plan to waive the copayment for an x-ray. You say that you do not agree with 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 $100 copayment for outpatient diagnostic tests/x-rays/outpatient hospital facility.

You have been asked to pay $74.39 which is less than your copayment amount of $100 for an x-ray. The correct copayment has been applied to the diagnostic imaging that was provided. An x-ray falls within the outpatient diagnostic tests/x-rays/outpatient hospital facility 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 x-ray provided by a participating hospital facility on February 25, 2021.