Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2025) polycarbonate lens (V2784) progressive lens (V2781).

You asked the Plan to pay for the vision services. You say that you are requesting reconsideration of reimbursement for the services. The Plan denied your request. The Plan says the maximum benefit amount has been exceeded.

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 this benefit only once per year. Any remaining benefit dollars do not roll over to a future purchase. The records show that the plan had already provided this benefit.

We looked at the file and the Plan's rules. The plan covers $500 towards the purchase and fitting of eyeglasses or contact lenses at a network optical provider once per year. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for deluxe frames (V2025) polycarbonate lens (V2784) progressive lens (V2781).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services.

You asked the Plan to waive the copayment for specialist services. You say that you were admitted to the hospital and should not owe office visit 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialist services.

You received specialist services on June 9, 2020. Therefore, you are responsible to pay the allowed amount of $32.90, which is less than the $40 copayment. Please note, this is in your financial favor as the cost-sharing is less than inpatient hospital services.

You have been asked to pay $32.90 for specialist services. Specialist services fall within the physician/practitioner services, including doctor's office visits 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 specialist services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Outpatient Surgery - Spinal Fusion, Cervical (CPT
code(s) 22552, 22845, 22551 and 20931).

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the enrollee's records do not show their nerves or spinal cord being pinched. The Plan
states it does not show a tumor or infection near the enrollee's spine and the records also do not show broken
bones or bones that have not healed after another surgery.

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 services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the criteria for spinal surgery not met. The imaging studies do not show severe stenosis or
neural compression. There is no instability. Surgery is not needed based on the imaging studies and physical
exam showing no deficit neurologically.

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 pre-approve Outpatient Surgery - Spinal Fusion, Cervical (CPT code(s) 22552, 22845, 22551 and
20931).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services received by an out of network (OON) provider.

You asked the Plan to pay for the vision services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when received from an out of network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. 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 the vision services received by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services (83036, 85025, 80061, 36415, 80053, 82248 and 86480) provided by an out of network (OON) provider.

You asked the Plan to pay for the lab services. You say that you do not have a primary care physician and your care is coordinated by a state mental health service provider. You did not realize that these services were out-of-network or required prior authorization, and request that the Plan cover them as part of your annual health screenings. The Plan denied your request. The Plan says when you enrolled with the Plan, you selected a primary care physician to coordinate and authorize your medical care. These services were not referred by the primary care physician, nor were they pre-approved or urgent. Out-of-network care is only covered in limited circumstances.

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. Care needs to be coordinated by a primary care physician as directed by the Plan. 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 the lab testing services (83036, 85025, 80061, 36415, 80053, 82248 and 86480) provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and diagnostic testing provided by an out of network (OON) provider.

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 were rendered by an out-of-network provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. 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 the office visit and diagnostic testing provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve harness for upgrade to expandable controller (CPT code
E2313), expandable controller (E2377), and electronic connection between wheelchair controller and two or
more power seating system motors (E2311).
You asked the Plan to pre-approve the DME. You say that you are losing mobility and are unable to leave
home. The Plan denied your request. The Plan says the requested items exceed your needs and cannot be
covered. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this
information, we decided that Medicare rules for coverage of the DME have not been met. The upgraded
electronics (expandable controller, harness and electronic connector to 2 power options) are not medically
necessary. They are necessary where there is a medical need to control power options through the joystick. The
notes do not show a medical need to control the power options through the joystick. The power options can be
controlled using their own switches. Therefore, we decided that the Plan does not have to pre-approve harness
for upgrade to expandable controller (CPT code E2313), expandable controller (E2377), and electronic
connection between wheelchair controller and two or more power seating system motors (E2311).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery to place a Vertiflex Superion device (CPT code
22869, 22870 and C1821) for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the services are considered experimental and investigational.

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 services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the
device.

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 pre-approve surgery to place a Vertiflex Superion device (CPT code 22869, 22870 and C1821) for the
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.

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 the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for weakness and cholecystitis. Medical problems are stable. There are no complex nursing or
rehabilitation needs. The enrollee does 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. There is not a
reasonable expectation that this enrollee 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 acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the complete series x-ray (D0210).

You asked the Plan to waive the cost share for the dental service. You say that you called the Dental Plan before going to the dentist. You say that you were told that there would be no copay for a cleaning. You also say that you received a bill for $54.50. The Plan denied your request. The Plan says you pay a 50% coinsurance for Class 2 Basic Services, including complete series x-ray.

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, there is a 50% coinsurance for Class 2 Basic Services, including the complete series x-ray. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the cost share for the complete series x-ray (D0210).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit.

You asked the Plan to pay for office visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim must be processed by the enrollee's primary insurance carrier before it can be processed by the Plan.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed you to submit this claim to the enrollee's primary insurance carrier. As the secondary insurer, the Plan cannot be held responsible for office visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for an office visit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
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. You were admitted for
weakness and a urinary tract infection. Medical problems are stable. There are no complex nursing or
rehabilitation needs. 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. 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 acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral exam (D0120) and prophylaxis (D1110).

You asked the Plan to reimburse you for the dental services. You say that you have been with this plan for many years. You say that you were never advised that your dentist's status with your plan had changed. You say that your coverage clearly states that you can see any dentist. You also say that you feel that this denial is unfair. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made to providers who have 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, dental services that you receive from a provider who has opted out of Medicare are not covered under this benefit. The Evidence of Coverage clearly states that if you use a provider that has opted out of Medicare you will not receive reimbursement. Therefore, we decided that the Plan does not have to reimburse you for the oral exam (D0120) and prophylaxis (D1110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide shoulder brace (L3960).

You asked the Plan to provide shoulder brace. You say that the item should be covered. The Plan denied your request. The Plan says there is insufficient documentation.

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 provide shoulder brace. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found without a physical examination or full exhaustion of physical therapy, the shoulder brace is not medically 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 shoulder brace have not been met. Specifically, there is no documentation indicating the medical necessity of the item provided. Therefore, we decided that the Plan does not have to provide shoulder brace (L3960).
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.
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. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (87804, 99215, 87880, 96372) provided by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were provided without prior authorization and OON criteria for coverage are not met.

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 the office visit (87804, 99215, 87880, 96372) provided by an out of network (OON) provider.