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

We decided that the Plan does not have to pay for refraction provided on May 8, 2021.
You asked the Plan to pay for determination of refractive state (92015). You say that the doctor is an in-network doctor on the Plan's provider directory. The Plan denied your request. The Plan says the eye refraction service is not covered since it was a medical vision check.
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 eye refraction during a routine exam. We looked at the file and the Plan's rules. The diagnosis code (H25.13), age-related nuclear cataract, bilateral makes this a medical exam. Eye refractions are only covered by the Plan if performed as a routine screening. Based on this information, we decided that the Plan's rules for coverage of determination of refractive state (92015) have not been met. Therefore, we decided that the Plan does not have to pay for refraction provided on May 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says your records do not show you do not require skilled nursing services or skilled rehabilitation services on a daily basis and which can only be provided on an inpatient basis in a SNF, your rehab and medical needs can be met with part-time skilled services in a lower level of care, such as home with supervision and home health services. The Plan states home health services will need to be approved by your health plan. The Plan states your rehabilitation needs can safely be at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are ambulating more than one-hundred (100) feet and tending to activities of daily living (ADLs) with minimal supervision. At this point, your care needs, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 12, 2020.
You asked the Plan to pay for the testing services. You say that physicians send specimens for testing. The Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The claim provided listed the place of service as an independent lab. The records do not indicate the specimen at issue was obtained at an independent lab. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on November 12, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology interpretation services provided on July 6, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the predictive screening is not a covered benefit.
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 G0452 is molecular pathology procedure; physician interpretation and report. We find that CPT code G0452 is not supported in the medical record. Specifically, the records do not show that the services were provided due to abnormal signs or symptoms of the enrollee. The services are not covered for the screening diagnosis listed on the claim. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the molecular pathology interpretation services provided on July 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for fillings (D2335, D2331) provided on
January 18, 2021.
You asked the Plan to pay an additional amount for fillings. You say that you cannot afford to pay the charges.
The Plan denied your request. The Plan says the services at issue are covered benefits, however the benefit
maximum had already been met.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of fillings have not been met. Specifically, the record shows that you had exhausted your dental
benefit maximum and the remaining amount is your contractual responsibility. Therefore, we decided that the
Plan does not have to pay an additional amount for fillings (D2335, D2331) provided on January 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on February 21, 2021.
You asked the Plan to pay for the ambulance service. You say that ambulance service is covered with a $0 copayment. You also say that this claim should be paid immediately as the provider keeps sending invoices. The Plan denied your request. The Plan says the ambulance benefit is for transportation only. The Plan also says that since there was no transportation actually rendered, the service is not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.
The ambulance company did not provide transport services on February 21, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on February 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan
denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 the SNF care. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found skilled therapy and skilled nursing is not
required on a daily basis in an inpatient setting.
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 SNF care have not been met. Specifically, medically necessary services can
be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor provided on January 13,
2021.
You asked the Plan to pay for the provided device. The Plan denied your request. The Plan says the
documentation did not support the necessity for the billed supply code.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation does not indicate that the enrollee performs blood glucose testing at least four times per day or had an in-person visit with their treating physician to assesses a need for a CGM regimen. Based on this information, we decided that Medicare rules for coverage of the provided device have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor provided on January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), the initial periapical x-ray (D0220), the additional periapical x-rays (D0230 x 4), and the panoramic x-ray (D0330) provided on September 30, 2020.
You asked the Plan to pay for the dental services provided on September 30, 2020. You say that you were referred to this office by your plan. You say that the dental office advised they do not accept your insurance. You also say that you should not be responsible for this bill. The Plan denied your request. The Plan says the oral evaluation and x-rays are not listed as covered 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, the oral evaluation and x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), the initial periapical x-ray (D0220), the additional periapical x-rays (D0230 x 4), and the panoramic x-ray (D0330) provided on September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and eye ultrasound provided on May 28, 2021.
You asked the Plan to waive the copayment for the office visit and eye ultrasound. You say that the first bill showed you owe a total of $10 and the second bill showed you owe $50 for the same services. You say that you want to know why a second copayment was added and you are appealing having to pay more. The Plan denied your request. The Plan says the claim reprocessed to apply a $40 copayment to the office visit and the original $10 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 each office visit or telehealth visit to your POC, or other primary care provider, or a $40 copayment for each office visit or telehealth visit to other network providers and a $10 copayment for x-rays, laboratory and other diagnostic tests. You have been asked to pay a $40 copayment for the office visit a $10 copayment for the eye ultrasound. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The eye ultrasound falls 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 copayment for the office visit and eye ultrasound provided on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 1, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 6, 2020.
You asked the Plan to pay for the services provided. You say that physicians send specimens for testing. The Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The billed claim lists the place of service as an independent laboratory. The records do not show that the services were obtained an independent laboratory. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on November 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant
(D6010) and implant supported crown (D6066) provided on March 11, 2021.
You asked the Plan to pay for the endosteal implant and implant supported crown. You say that you need SNF care.The Plan denied your request. The Plan says these services are not covered under your plan.
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
surgical placement of implant body: endosteal implant (D6010) and implant supported crown (D6066)
provided on March 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone.

You asked the Plan to pre-approve Prednisone. You say that the drug is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.

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 Prednisone.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on December 24, 2020. You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were asked if you wanted to be taken to the hospital, but declined because the pain had subsided, the exam and testing you already received would have been repeated at the hospital, and you would have had no way home. The Plan denied your request. The Plan says if there is no ambulance transport the service is not covered. The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 24, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on December 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on August 18, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames (V2020) and progressive lenses (V2781) provided March 27, 2021.

You asked the Plan to pay for the frames and progressive lenses. You say that you would like the eyewear covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for routine eyewear and therefore it is not covered.

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 eyeglass frames every 24 months and eyeglass lenses every 12 months. 

We looked at the file and the Plan's rules. The Plan provided documentation showing that routine eyewear was covered by the Plan on April 26, 2021. Based on this information, we determined that the frames and progressive lenses purchased March 27, 2021 are not eligible for coverage. Therefore, we decided that the Plan does not have to pay for the frames (V2020) and progressive lenses (V2781) provided March 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) provided on
December 21, 2020.
You asked the Plan to pay for the complete maxillary denture. You say that your dental benefits say you would
be covered up to $1,000 per year, and you have only used $355.25 of that amount. The Plan denied your
request. The Plan says this service is not a covered benefit under your dental plan.
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 maxillary denture (D5110) provided on December 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on December 29, 2020.
You asked the Plan to pay for the ambulance service. You say that the enrollee slipped and fell in the garage upon returning home from the hospital. You say that the enrollee's legs were swollen to the point that he could not walk. You also say that you were not able to pick up the enrollee on your own. The Plan denied your request. The Plan says the policy only covers ambulance services when transported to the nearest appropriate facility for medical treatment.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 29, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on December 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study for the enrollee.
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 the study. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found a diagnostic polysomnography is considered not medically necessary. The enrollee has hypertension, but there is no excessive daytime sleepiness, snoring, observed apneas, or morning headaches. The enrollee is not obese. This study is not justified. 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 study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study for the enrollee.