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

We decided that the Plan does not have to pay for anesthesia services (99100) provided June 18, 2020.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says payment for these services was included in another code 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. We find that CPT code 99100 is not supported in the medical record. Specifically, this code is not separately payable. Payment for this service was included in CPT code 01810. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided June 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on November 2, 2020.
You asked the Plan to waive the coinsurance for DME. You say that you were not informed of the benefit
changes and did not approve them. 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 20% coinsurance for DME.
The enrollee received DME on November 2, 2020. The total allowed amount is $134 and 20% of that is
$26.80.
The enrollee has been asked to pay the total coinsurance amount of $26.80 for DME. DME falls within the
DME 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 coinsurance for DME provided on
November 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ertapenem.
You asked the Plan to pre-approve Ertapenem. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Ertapenem.
Benefits for Ertapenem may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item was medically necessary for the enrollee. The Plan denied your request. The Plan says the patient did not receive video or telephonic visit by the ordering physician to warrant the code billed.
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is 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 lumbar-sacral orthosis. Our reviewer says that the item provided was not medically necessary and reasonable. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation and a credible physical examination of the back.
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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on November 17, 2020, by an OON
provider.
You asked the Plan to pay for the prophylaxis. You say that you would like this service to be covered. The Plan
denied your request. The Plan says this service was rendered by an OON provider. The Plan also says that you
are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you
for the services.
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, you are responsible for a 50%
coinsurance when the service is received OON, and you are also responsible for the difference between the
billed amount and the amount that was paid by the Plan for services received OON. The record also shows that
you did not contact the Plan prior to this date of service to verify benefits and provider eligibility. Therefore,
we decided that the Plan does not have to pay for the prophylaxis provided on November 17, 2020, by an OON
provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dronabinol.
You asked the Plan to pre-approve Dronabinol. You say that you would like reconsideration because the member has been successfully using this medication to treat their condition. The Plan denied your request. The Plan says this drug is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dronabinol.
Benefits for Dronabinol may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
October 12, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
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 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP supplies.

You asked the Plan to waive the coinsurance for the CPAP supplies. You say that you were informed you had met your deductible and out-of-pocket expense. You say that you should be refunded your copayment. 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 after your yearly deductible is met, you pay 20% for Medicare-covered equipment and supplies.

You have been asked to pay $43.44, which is 20% of the allowed amount for the CPAP supplies. The allowed amount is $217.24 (20% x $217.24 = $43.44). CPAP supplies falls within the "Durable medical equipment (DME) and related supplies" benefit category. The records show your maximum out-of-pocket was not met. 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 CPAP supplies.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for Excision, malignant lesion (11622, 11603) intermediate
wound repair (12032, 12042) provided on October 8, 2020, by an OON provider.
You asked the Plan to pay for the surgical procedure. You say that you are requesting an appeal in regard to
denied claim. Attached are the medical notes for further review. The Plan denied your request. The Plan says
enrollee's must receive their medical services from an in-network provider with the exception being urgent or
emergent services. Non-emergent services with non-contracted providers require prior authorization before
services being rendered.
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 Excision, malignant lesion (11622, 11603)
intermediate wound repair (12032, 12042) provided on October 8, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bifocal lens (V2203) and polycarbonate lens (V2784)
provided August 23, 2018.
You asked the Plan to pay for the bifocal lens and polycarbonate lens. You say that you would like your glasses
covered in full. The Plan denied your request. The Plan says your $100 benefit limit for eyewear has been met,
therefore you are responsible for the remaining cost of the lenses.
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 supplemental eyewear up to $100 every year.
We looked at the file and the Plan's rules. The Plan provided documentation that your $100 eyewear benefit
was exhausted when purchasing your frames and lenses on August 23, 2018. Therefore, you are responsible for
the remaining cost of the bifocal lens and polycarbonate lens. Therefore, we decided that the Plan does not
have to pay for the bifocal lens (V2203) and polycarbonate lens (V2784) provided August 23, 2018.
Your complaint about not receiving a timely copy of your decision letter from the Plan 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for MRI's provided on December 17, 2020.
You asked the Plan to waive the copayments for MRI's. You say that you feel you should only owe one copayment, not two for the MRI's because they were completed at the same time. 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 $225 copayment for each advanced imaging service. You received MRI's on December 17, 2020. Therefore, you are responsible to pay a $225 copayment per each MRI. However, you are only being asked to pay $404.02, which is less than the total copayment amount. You have been asked to pay $404.02 for MRI's. MRI's fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for MRI's provided on December 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673).
You asked the Plan to pay for a pneumatic compression device. You say that this item was medically necessary for the enrollee. The Plan denied your request. The Plan says this is not a covered service.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression to treat peripheral artery disease is not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) and a complete lower denture (D5120) provided on August 18, 2020.
You asked the Plan to pay for the dental items. You say that you were under the impression that your coverage included dentures. You say that the provider's office advised that the dentures would be covered. You say that you would not have gotten the dentures otherwise. You say that you did not have any teeth and were not able to eat properly. You also say that you were worried about your nutrition. The Plan denied your request. The Plan says dentures are not listed as covered dental items. The Plan also says that any services not listed are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and a complete lower denture (D5120) provided on August 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the gastrointestinal procedures.

You asked the Plan to pay for the nasal surgery procedure (30999) and introduction of long gastrointestinal tube (44500). You say that the Plan should pay this claim. The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services.

The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary during an inpatient stay. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers.

This was an inpatient service. Payment for this service would have been included under the global facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for the gastrointestinal procedures.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you would prefer to be discharged to an acute rehab so you can have the medical management and therapy that will help you. The Plan denied your request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have not been met.
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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Our physician reviewer also found that there is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 the acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 20, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 physician's 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 physician's services provided on August 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Sure Grip A401, brake only hand controls for an automobile (A9270) purchased October 20, 2020 from an out of network provider.
You asked the Plan to pay for the brake only hand controls for an automobile. You say that you did not file this as a Wellness Program claim, but rather in accordance with the plan's DME coverage. You provided your PCP's statement that the hand control is medically necessary for you to drive. The Plan denied your request. The Plan says this item is not a covered benefit. Enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered
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. 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. Therefore, we decided that the Plan does not have to pay for Sure Grip A401, brake only hand controls for an automobile (A9270) purchased October 20, 2020 from an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive service (D1999) provided on
November 23, 2020.
You asked the Plan to pay for the unspecified preventive service. You say that a plan representative advised
that your dental coverage is 100% up to $2,000 and no copay. You also say that now you are being told that
you have to pay $310. The Plan denied your request. The Plan says the unspecified preventive service is not
listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
unspecified preventive service (D1999) provided on November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyewear purchased on January 18, 2019, which included frames (V2020), bifocal lenses (V2203, V2204) and progressive lens upgrades (V2781).
You asked the Plan to pay for the eyewear. You say that you believed the eyewear was pre-approved and do not understand why you are now receiving a denial. The Plan denied your request. The Plan says you had exhausted your benefit for the 2019 plan year. The Plan has paid $150 towards the glasses that you purchased on January 18, 2019 but cannot fully pay for them as the total cost of the eyewear exceeds the Plan's maximum annual allowance.
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 up to $150 for supplemental eyewear every year. We looked at the file and the Plan's rules. Based on this information, we decided that the maximum allowance indicated in the contract had been met. Therefore, we decided that the Plan does not have to pay the full cost of the eyewear purchased on January 18, 2019, which included frames (V2020), bifocal lenses (V2203, V2204) and progressive lens upgrades (V2781).
Your complaint about possible confusion regarding a delayed partial denial from the Plan 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.