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

We decided that the Plan does not have to pay for thyroid testing (84443) provided June 8, 2020.
You asked the Plan to pay for thyroid testing. You say that you are resubmitting the claim with medical record and waiver. Please review for payment. The Plan denied your request. The Plan says CPT 84443 is not a Medicare benefit for the diagnoses listed on the claim and are done for screening purposes.
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 thyroid testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request for thyroid hormone does not meet NCD criteria. Further, there is no indication for LH and FSH in a male patient. The request was not medically reasonable or 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 thyroid testing have not been met. Therefore, we decided that the Plan does not have to pay for thyroid testing (84443) provided June 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from March 25, 2020, through March 26, 2020 and April 20, 2020, through April 28, 2020.

You asked the Plan to waive the copayment for the inpatient stays. You say that you were misled. You say that you were informed your coverage would be the same, but you have several bills that were not paid. The Plan denied your request. The Plan says the copayments 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 $325 copayment each day for days 1 to 5 for in-network, Medicare-covered hospital care. $0 for additional Medicare-covered days. 

You have been asked to pay a total of $1,950 for the inpatient stays.

Date of Service             Service                Standard Copayment             Member Liability
March 25, 2020 -
March 26, 2020          Inpatient Stay                   $325/day                              $325

April 20, 2020 -
April 28, 2020            Inpatient Stay                    $325/day                             $1,625
   TOTAL:                                                                                                     $1,950

The inpatient stays fall within the "Inpatient Hospital 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 the inpatient stay provided from March 25, 2020, through March 26, 2020 and April 20, 2020, through April 28, 2020.

Your complaint about fraudulent conditions and practices 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.
You asked the Plan to pre-approve Eylea. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Eylea. Our reviewer says that the
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer
found the enrollee has exudative age-related macular degeneration, left eye, with active choroidal
neovascularization. The documentation does not support that the enrollee has tried and failed Avastin
(bevacizumab). The documentation does not support an indication that the plan's required drug would likely be
less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to
pre-approve Eylea.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered when billed by a chiropractor.

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. The file shows that the provider billed code 99203 (office visit). Therefore, we decided that the Plan does not have to pay for the office visit.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit.

You asked the Plan to waive the copayment for the emergency services. You say that you are asking the Plan not to pay any charged received from the hospital, for the hospital to refund any charges from your credit card as you believe the care you received was below the standard of care expected. The Plan denied your request. The Plan says the claim was processed, and the correct copayment was applied per the Evidence of Coverage.

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 $90 copayment for emergency room services for Emergency care.

You have been asked to pay $180 ($90 + $90 = $180) copayment for emergency room services. The emergency services fall within the Emergency 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 the emergency department visit.

Your complaint about the care you received at the hospital 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a respiratory viral panel of 3-5 pathogens (87631) provided on August 11, 2020.
You asked the Plan to pay for a respiratory viral panel. You say that this was medically necessary. The Plan denied your request. The Plan says the criteria for coverage were not met.
The Plan must follow Medicare rules. Medicare rules say that respiratory viral panels of 3-5 pathogens test must be ordered either in a healthcare setting that is equipped to care for and routinely does care for critically ill patients, or it must be ordered by an infectious disease specialist, unless an infectious disease specialist is not available. We looked at the file and Medicare rules. The submitted medical records do not show that the test at issue was ordered in a healthcare setting that is equipped to care for and routinely does care for critically ill patients or by an infectious disease specialist. Based on this information, we decided that Medicare rules for coverage of a respiratory viral panel have not been met. Therefore, we decided that the Plan does not have to pay for a respiratory viral panel of 3-5 pathogens (87631) provided on August 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic imaging provided by an out of network (OON) provider.

You asked the Plan to pay for diagnostic imaging. 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 a participating provider or facility.

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 diagnostic imaging provided 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 provided on August 4, 2020.
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 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 the laboratory services are not supported in the medical record. Specifically, these services should be billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for mobile x-ray services (Q0092, R0070) provided September 21, 2020.
You asked the Plan to pay for the mobile x-ray services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid place of service.
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 Q0092, & R0070 are not supported in the medical record. Specifically, Place of Service 31 was billed, however the record does not show a covered Part A SNF stay. Based on this information, we decided that Medicare rules for coverage of the mobile x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for mobile x-ray services (Q0092, R0070) provided September 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3002).
You asked the Plan to pre-approve foot orthotics. You say that the orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3002).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for administration of influenza virus vaccine (G0008) influenza vaccine (90662) provided by an out of network (OON) provider.

You asked the Plan to pay for the injection services. You say that the plan keeps saying you need a prior authorization. You called on these claims and no prior authorization is needed. You sent them back and they all denied saying they were a duplicate claim. The Plan denied your request. The Plan says enrollee's must receive 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 administration of influenza virus vaccine (G0008) influenza vaccine (90662) provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown lengthening procedure (D4249).
You asked the Plan to pre-approve the crown lengthening procedure. You say that you expected the Plan would pay for this service because you have dental coverage. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental benefit.
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 pre-approve the crown lengthening procedure (D4249).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the tooth extraction (D7210) provided November 9, 2020.
You asked the Plan to pay for the tooth extraction. You say that you called and were told the service would be covered at 50%. The Plan denied your request. The Plan says the service is not covered under your extra benefits.
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, extractions are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the tooth extraction (D7210) provided November 9, 2020.
Your complaint about potentially being given misinformation by a plan representative 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot feature and rotational unit.
You asked the Plan to pre-approve a prosthetic leg with an advanced foot feature and rotational unit. You say that the requested prosthetic leg with an advanced foot feature and rotational unit is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested prosthetic leg with an advanced foot feature and rotational unit.
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 a prosthetic leg with an advanced foot feature and rotational unit. Our reviewer says that the enrollee does not meet criteria for the requested prosthetic leg with an advanced foot feature and rotational unit. Our physician reviewer found based on the medical records provided by the prescribing provider there is no documentation that the enrollee meets Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) criteria for the advanced foot feature and rotational unit. Records from the prescriber do not document that the enrollee has level 3 ability. (Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion). The requested prosthetic leg has been approved by the health plan but based on the medical records provided by the prescribing provider there is no documentation that the requested advanced foot feature and rotational unit are medically reasonable and necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a prosthetic leg with an advanced foot feature and rotational unit have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot feature and rotational unit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient hospital care.
You asked the Plan to pay for acute inpatient hospital care. You say that the records provided support the need
for an inpatient hospital stay. The Plan denied your request. The Plan says the enrollee does not meet any of the
requirements for an inpatient stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the enrollee was being treated for osteoarthritis of the left knee. The February 18,
2021, treating physician report cites increased left knee pain for over 6 weeks. He felt pain after twisting while
lifting some boxes. There is pain and swelling with limited flexion. There is pseudo locking and pain at night.
Exam reveals active left knee range of motion of flexion 105 and extension 7 with pain. There is decreased left
quadriceps strength. There is a limp noted on gait. There is mild effusion and swelling noted. There is
tenderness of the medial joint line. There is extensor lag noted of 1-10 degrees. The left total knee arthroplasty
is noted to have been supported. Detailed documentation is not evident regarding any significant risk factors
that would require inpatient care post-surgery. Peer reviewed literature demonstrates that total knee
arthroplasties are safely able to be performed outpatient or at a 23-hour stay. There is no compelling rationale
presented or extenuating circumstances noted to support the medical necessity of this request as an exception.
Therefore, the request for inpatient hospital admission is not medically reasonable or 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 acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoe inserts (A5500). You asked the Plan to pre-approve the diabetic shoe inserts. You say that the shoe inserts are medically necessary. The Plan denied your request. The Plan says the documentation does not support the need for the shoe inserts. The Plan must follow Medicare rules. Medicare rules say that the record must include detailed information about the condition that qualifies the beneficiary for coverage. We looked at the file and Medicare rules. The plan made multiple requests for additional medical records pertaining to the enrollee's diabetes diagnosis. Insufficient clinical documentation was provided. Based on this information, we decided that Medicare rules for coverage of the diabetic shoe inserts have not been met. Therefore, we decided that the Plan does not have to pre-approve diabetic shoe inserts (A5500).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lenses, bifocals (V2200) lens, polycarbonate (V2784) UV lenses (V2755) scratch resistant coating (V2760) purchased October 29, 2020.
You asked the Plan to pay for the vision services. You say that the plan's billing detail showed that you owed $66.66. You had paid $321.25 with your credit card. You presented this information to the provider with the demand you be reimbursed for overpayment. The Plan denied your request. The Plan says the claim was processed correctly and the correct cost share was applied per the Evidence of Coverage.
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 $321.25 any amount over $375 retail price towards the purchase and fitting of eyeglasses or contact lenses and any services not covered by the plan. for Vision care. You have been asked to pay $321.25 any amount over $375 retail price towards the purchase and fitting of eyeglasses or contact lenses and any services not covered by the plan. for the vision services. The total retail price for the glasses was $564.24. The plan paid $224.99. The $66.66 is included in the $321.25 that you paid to the provider. There were additional items that are not covered under the plan benefits. the vision services 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 pay for lenses, bifocals (V2200) lens, polycarbonate (V2784) UV lenses (V2755) scratch resistant coating (V2760) purchased October 29, 2020.