Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cross-facial nerve graft.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is currently receiving Botox to treat hemifacial spasm. There is sparse documentation of the current function of her facial nerve on the left. There is no documentation of the reason for the facial nerve procedure. It is unclear why the surgical procedure was offered to this enrollee and what the expected benefit and outcome will be. The documentation does not support that the requested procedure is reasonable or medically necessary for 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a cross-facial nerve graft.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lenses, Bifocals (V2200).
You asked the Plan to pre-approve the vision services. You say that you did not get glasses last year because the optometrist informed you that your prescription has not changed, and you just have cataracts. You have had
your current pair of glasses for 4 years. The Plan denied your request. The Plan says this request exceeds the maximum benefit allowance for 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. The Plan covers these services when every 2 years. We looked at the file and the Plan's rules. The Plan covers a $275 coverage limit for eye wear (contact lenses and eyeglasses) every 2 years. The records show that your benefit allowance was last used for eyewear on dates of service February 13, 2020 and February 26, 2020. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pre-approve the lenses, Bifocals (V2200).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on March 2, 2021, by
an out-of-network (OON) provider.
You asked the Plan to pay for an electrocardiogram. You say that you would like reconsideration for this
procedure as the Plan's authorization lookup tool advised no authorization was required. The Plan denied your
request. The Plan says services were provided by an out-of-network provider without 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. There is a provider lookup tool on
the Plan's website that tells providers if the service they are going to provide needs authorization or not.
However, the lookup tool has a disclosure that says, this tool is for general information only. It does not take
into consideration a specific member or contract agreement. 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 electrocardiogram (93010) provided on March 2, 2021, by an out-of-network
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 0242U provided on April 6, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered 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. The documentation shows that these laboratory services were billed with diagnosis code C34.90 (Malignant neoplasm of unspecified part of unspecified bronchus or lung). The documentation does not include documentation that shows these services were not provided for screening purposes. This means that the laboratory test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 0242U provided on April 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for scanning computerized ophthalmic diagnostic imaging (92133) and does not have to pay for an eye refraction (92015) provided on April 1, 2021.
You asked the Plan to waive the copayment for scanning computerized ophthalmic diagnostic imaging (92133) and to pay for an eye refraction (92015). You say that there should not be any charge for the eye exam. The Plan denied your request. The Plan says the claim was processed 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 $35 copayment for Vision Care.
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
You have been asked to pay a $35 copayment for scanning computerized ophthalmic diagnostic imaging (92133). A scanning computerized ophthalmic diagnostic imaging (92133) falls within the Vision 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 scanning computerized ophthalmic diagnostic imaging (92133) provided on April 1, 2021.
The file shows that you received an eye exam for a Medicare-covered eye condition and not a routine eye exam. The file shows that part of this exam was for a refraction. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for telehealth services provided to the enrollee on January 19, 2021.
You asked the Plan to pay for telehealth services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for an out of network service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that telehealth services must be provided in network. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided telehealth services. 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 telehealth services provided to the enrollee on January 19, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral exam (D0150), prophylaxis (D1110), periapical x-ray (D0220), additional periapical x-ray (D0230), bitewing x-rays (D0274), and the panoramic x-ray (D0330) provided on May 22, 2021.
You asked the Plan to pay for the dental services. You say that you found this provider on the plan's website. You say that when you called to make an appointment you were not aware that the provider was out of network. You also say that now you have a bill and you cannot pay it. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services performed out of network 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, dental services performed out of
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150), prophylaxis (D1110), periapical x-ray (D0220), additional periapical x-ray (D0230), bitewing x-rays (D0274), and the panoramic x-ray (D0330) provided on May 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete series of intraoral x-rays (D0210) provided on June 16, 2021.
You asked the Plan to pay for the complete x-ray series. You say that you called the Plan prior to services and were not told which type of x-rays are covered. You also say that you specifically chose an in-network provider and are frustrated that the provider did not tell you this type of x-ray was not covered. The Plan denied your request. The Plan says this type of x-ray is not covered by your dental benefits. The Plan also says that they reviewed your call to customer service and found that the type of x-rays covered was included in this call.
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 a complete series of intraoral x-rays (D0210) provided on June 16, 2021. Your complaint about a potential lack of information regarding covered services from 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the consultation (D9310) and drugs or medicaments (D9630) provided on March 5, 2021.
You asked the Plan to reimburse you for the dental services. You say that you are on a limited monthly income. You also say that you have other bills that you need to pay. The Plan denied your request. The Plan says up to a $500 allowance may be applied to covered comprehensive dental services every year. The Plan also says that the benefit maximum has been exhausted.
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 annual allowance has been exhausted. The record shows that the Plan paid $43 for dental services performed on February 3, 2021, $166 for dental services performed on February 9, 2021, and $291 for dental services performed on March 1, 2021. $43+$166+$291=$500. Therefore, we decided that the Plan does not have to reimburse you for the consultation (D9310) and drugs or medicaments (D9630) provided on March 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided the Plan does not have to pay for medical services provided to the enrollee on October 5, 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 due to the enrollee's hospice status at the time of service, this claim must be submitted to Original Medicare first. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from September 21, 2020 to October 16, 2020.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the services billed by your provider are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services provided from September 21, 2020 to October 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 21, 2021 by an out-of-network
(OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. You say
that your lab performed all the tests that were ordered by the referring physician. 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 lab work provided on January 21, 2021 by an outof-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on October 9, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that you are in-network with the member's Plan. You also say the services were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider. 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 (99213) provided on October 9, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inflatable tub.
You asked the Plan to pre-approve inflatable tub. You say that you cannot physically get into the shower/bathtub and this will help your hygiene. The Plan denied your request. The Plan says this item is not covered by Medicare.
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 an inflatable tub.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code E1399.
You asked the Plan to pre-approve the compression stockings. You say that these stockings are medically necessary because when you try to walk without them your ankle and foot hurts and swells. You got a pair in 2005 and they were covered. They are worn out now and cost over $300. The Plan denied your request. The Plan says the requested item does not meet the definition of DME and is considered non-reusable supply and not a rental type item.
The Plan must follow Medicare rules. The rules say that compression stockings described by code E1399 are noncovered because they do not meet the statutory definition of a surgical dressing. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code E1399.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear interpretation (85060) provided on January 17, 2021.
You asked the Plan to pay for the blood smear interpretation. You say that you would like reconsideration because this service was billed with the appropriate place of service code. The Plan denied your request. The Plan says per Medicare guidelines, this claim was billed with an inappropriate place of service for physician interpretation. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that no payment is recognized for code 85060 furnished to hospital outpatients or non-hospital patients. In this case, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by physician with written report. We find that CPT code 85060 is not supported in the record. Specifically, no payment is recognized for code 85060 furnished to hospital outpatients or non-hospital patients. This claim was billed with an outpatient place of service code. Based on this information, we decided that Medicare rules for coverage of the blood smear interpretation have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear interpretation (85060) provided on January 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the remote pacemaker test you had on March 5, 2021.
You asked the Plan to waive the copayment for the remote pacemaker test. You say that it is not fair to have a copayment for this service because you didn't see or talk to a doctor. The Plan denied your request. The Plan says you were charged this copayment 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 $35 copayment for diagnostic procedures and tests. You have been asked to pay a $35 copayment for the remote pacemaker test. The remote pacemaker test falls within the diagnostic procedures and tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the remote pacemaker test you had on March 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for current procedural terminology (CPT) codes 99223 and 99497 billed for date of service February 12, 2021.
You asked the Plan to pay for CPT codes 99223 and 99497. You say that the medical documents sent are enough to substantiate the services performed. The Plan denied your request. The Plan says the records received did not support the coding criteria for the CPT codes 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 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. The CPT Code Manual definition of code 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. We find that CPT codes 99223 and 99497 are not supported in the medical record. The enrollee was admitted after a syncopal episode in the emergency room after a laceration repair. The services that are described by the CPT codes in dispute are not represented in the medical documentation that was provided. The case file shows that the Plan made reasonable attempts to obtain complete medical records which would demonstrate the services billed were in fact provided. This evidence was not supplied. Based on this information, we decided that Medicare rules for coverage of CPT codes 99223 and 99497 have not been met. Therefore, we decided that the Plan does not have to pay for current procedural terminology (CPT) codes 99223 and 99497 billed for date of service February 12, 2021.