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

We decided that the Plan does not have to pay for determination of refractive state (90215) provided November 11, 2020.

You asked the Plan to pay for the refraction services. You say that the medical records provided will show proof of medical necessity.The Plan denied your request. The Plan says refractive eye examinations are not covered when done as part of a medical eye appointment or in the presence of a medical eye diagnosis.

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 completed as part of a routine eye exam.

We looked at the file and the Plan's rules. Refraction services are only covered when done as part of a routine eye exam. The records show this was a medical eye appointment. Based on this information, we decided that the Plan's rules for coverage of the refraction services have not been met.Therefore, we decided that the Plan does not have to pay for determination of refractive state (90215) provided November 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Ozurdex (J7312) and administration (67028) provided on November 17, 2020.
You asked the Plan to pay for Ozurdex and administration. You say that this is a covered service. The Plan denied your request. The Plan says the use of this drug is not supported.
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 pay for Ozurdex and administration. Our reviewer says that the Ozurdex at issue is not supported. Our physician reviewer found Ozurdex is indicated or the treatment of macular edema following branch or central retinal vein occlusion. The record does not indicate that the enrollee has branch or central vein occlusion. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ozurdex and administration have not been met. Therefore, we decided that the Plan does not have to pay for Ozurdex (J7312) and administration (67028) provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on October 23, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that no services were provided by the urgent care facility so you should not be charged a copayment. The Plan denied your request. The Plan says the copayment 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 $10 copayment for Medicare-covered urgently-needed-care visits. You have been asked to pay a $10 copayment for the urgent care visit. The urgent care visit falls within the "Urgently Needed Services" benefit category. The records show that you were examined and given a prescription during the urgent care visit. 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 urgent care visit provided on October 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a walking boot provided on December 21, 2020.
You asked the Plan to waive the coinsurance for a walking boot. You say that you were told you would not owe anything. 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 20% coinsurance for prosthetic devices and related supplies. You received a walking boot on December 21, 2020. A walking boot is considered a prosthetic device. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $165.35 and 20% of that is $33.07. You have been asked to pay the total coinsurance amount of $33.07 for a walking boot. A walking boot falls within the prosthetic devices and related 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 coinsurance for a walking boot provided on December 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on December 28, 2020.

You asked the Plan to waive the copayment for the diagnostic mammogram. You say that if proper images were taken the first time there wouldn't have been a need to retake the images and incur an extra fee. You say that you are appealing the charge. The Plan denied your request. The Plan says the copayment 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 an $80 copayment for basic radiological services at an in-network outpatient hospital.

You have been asked to pay an $80 copayment for the diagnostic mammogram. The diagnostic mammogram falls 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 provided on December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on May 28, 2020.
You asked the Plan to pay for the ophthalmological services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the ophthalmological 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 ophthalmological services provided on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received from August 17, 2020, to October 16, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says you have reached the benefit limit.

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 $20 copayment per visit for up to 12 routine chiropractic visits per year.

The records show that the Plan has paid for 12 routine chiropractic visits for the 2020 calendar year. Any additional visits exceed the benefit limit. You are responsible for the full cost of any visits exceeding the benefit limit. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the chiropractic services you received from August 17, 2020, to October 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lab work and an EKG and copayment for an office visit provided by a non-participating provider on August 5, 2020, to December 2, 2020.
You asked the Plan to waive the deductible for lab work and an EKG and copayment for an office visit. You say that you think you are being charged incorrectly. The Plan denied your request. The Plan says the correct deductible and copayment have 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 deductible for outpatient diagnostic tests/lab and a $25 copayment for physician services/out-of-network. You have been asked to pay $42.12 towards your deductible for lab work and an EKG a $25 copayment for an office visit. The total amount you are being asked to pay is $117.12 ($42.12 + $75 ($25 x 3 office visits = $75) = $117.12). Lab work and an EKG falls within the outpatient diagnostic tests/lab benefit category and an office visit falls within the physician services/out-of-network 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 deductible for lab work and an EKG and copayment for an office visit provided by a non-participating provider on August 5, 2020, to December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
October 19, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the out of network provider is responsible for securing a 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 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 subsequent nursing facility care provided on October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on January 4, 2021.
You asked the Plan to waive the deductible for an office visit. You say that you are being charged more than the typical coinsurance amount and disagree with 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. Your contract with the Plan says that there is a $203 deductible for physician/practitioner services, including doctor's office visits. You had an office visit on January 4, 2021. The record shows that you had only paid $116.85 toward the $203 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible balance of $86.15. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible for physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on January 4, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on January 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-preferred brand of test strips.
You asked the Plan to pre-approve the non-preferred brand of test strips. You say that the enrollee wants to continue to use the non-preferred brand of test strips. The Plan denied your request. The Plan says the enrollee does not meet criteria for the non-preferred brand of test strips.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no physician documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the non-preferred brand of test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital hearing aids (V5261) purchased on December 16, 2020.
You asked the Plan to pay for the hearing aids. You say that you are supposed to have a $1,000 allowance per ear, so the Plan owes you $1,000 because you purchased two hearing aids. The Plan denied your request. The Plan says the benefit covers up to $1,000 towards hearing aids and batteries. You have already met this coverage maximum and any costs beyond this amount are your responsibility.
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. The Plan will pay a maximum $1,000 combined in and out-of-network benefit for batteries and hearing aids. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan has already paid the full $1,000 maximum for hearing aids and no additional amount is required. Therefore, we decided that the Plan does not have to pay for the digital hearing aids (V5261) purchased on December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the crown (D2740), bitewing x-rays (D0274), the prophylaxis (D1110), and the oral exam (D0120) provided from December 1, 2020, to December 2, 2020.
You asked the Plan to reimburse you for the dental services. You say that you are disappointed to find all of your dental claims denied. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for services performed by a provider that has opted out of Medicare.
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 and the services could be covered, dental services performed by a provider who has opted out of Medicare are not covered. Therefore, we decided that the Plan does not have to reimburse you for the crown (D2740), bitewing x-rays (D0274), the prophylaxis (D1110), and the oral exam (D0120) provided from December 1, 2020, to December 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for radiofrequency ablation to the SI joint (CPT code 64635) provided on June 16, 2020.
You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your request. The Plan says the services were not 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 pay for the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file is insufficient to demonstrate that the radiofrequency ablation to the SI joint performed on June 16, 2020, was medically reasonable and 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 services have not been met. Therefore, we decided that the Plan does not have to pay for radiofrequency ablation to the SI joint (CPT code 64635) provided on June 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care from April 23, 2021, forward.
You asked the Plan to pre-approve continued inpatient mental health care. You say that inpatient mental health care is medically necessary. The Plan denied your request. The Plan says this patient does not meet the level of care criteria for an acute inpatient psychiatric hospitalization but could be treated in a less restrictive setting.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient mental health care. Our reviewer says that the requested inpatient mental health care is not medically reasonable and necessary. Our physician reviewer found you are a 73-year-old man who was admitted to the acute inpatient psychiatric hospitalization on April 15, 2021, with Major Neurocognitive Disorder, Severe with Behavioral Disturbance and Unspecified Psychosis. Based upon review of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of April 23, 2021. You could have been treated in a less restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, or delusions. In addition, you were not showing any behaviors or aggression, you were being cooperative and compliant while not showing any acute threats to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health care from April 23, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies for a therapeutic CGM (K0553) provided on October 5, 2020.
You asked the Plan to pay for CGM supplies. You say that the requested item is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the document provided as proof of delivery indicates a requirement for a signature. No signature was provided. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for supplies for a therapeutic CGM (K0553) provided on October 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a history of hypertension, obesity, obstructive sleep apnea, and retinitis pigmentosa, who presented to the hospital with lightheadedness, shortness of breath, diaphoresis, and tachycardia. The enrollee met SIRS criteria, blood cultures were drawn, and antibiotics were administered. The enrollee has been working with physical therapy. The enrollee performs supine to/from sit with MAX x 2. The enrollee demonstrated difficulty scooting toward the edge of the bed. The enrollee reported increased pain in his lower extremities.

The documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires at least 3 hours a day/5 days a week, or 15 hours over 7 consecutive days, of therapy 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral x-ray (D0230) provided on August 5, 2020.

You asked the Plan to pay for the additional intraoral x-ray. You say that you needed these services urgently. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan also says that the frequency limit has been exceeded.

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 and intraoral x-ray is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid the out of network rate for the initial intraoral x-ray. Therefore, we decided that the Plan does not have to pay for the additional intraoral x-ray (D0230) provided on August 5, 2020.