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

We decided that the Plan does not have to pay for eyeglasses (V2020) and bifocal sphere lenses (V2200) provided on February 19, 2021.
You asked the Plan to pay for eyeglasses and bifocal lenses. You say that your copayment should have been
$10, and you are seeking a reimbursement of $3 as over payment. The Plan denied your request. The Plan says
you are responsible for the $10 copayment and any amount over the plan benefit maximum retail cost of $125
for eyewear benefit.
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 contract says that you pay a $10 copayment for one pair of eyeglasses or contact lenses per
year. The Plan contract also says that you are responsible for any amount over the plan's benefit retail cost of
$125 per year.
We looked at the file and the Plan's rules. The records show that the total retail cost for your eyeglasses was
$128. The records also show that a $10 copayment was applied and an additional $3 was charged as the retail
cost was over the maximum allowed amount of $125. Based on this information, we decided that the Plan's
rules for coverage of eyeglasses and bifocal lenses have not been met. Therefore, we decided that the Plan does
not have to pay for eyeglasses (V2020) and bifocal sphere lenses (V2200) provided on February 19, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for
transfer to an LTACH. The Plan denied your request. The Plan says that the enrollee's medical needs are being
met in the current acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a progressive lens (V2781), polycarbonate lenses (V2784) and anti-reflective coating (V2750) provided on February 23, 2021.
You asked the Plan to pay for a progressive lens, polycarbonate lenses and anti-reflective coating. You say that you believe your services should be covered. The Plan denied your request. The Plan says the services are not covered benefits under your Plan.
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 contract says you pay a 20% coinsurance for corrective lenses and/or frames after each cataract removal without a lens implant. The Plan contract also says upgrades are not a covered benefit. We looked at the file and the Plan's rules. The records show that the services at issue were upgrades, which are not a covered benefit. The records show that your total amount billed was $524. The Plan paid for one progressive lens which brought your total responsibility to $405.60. Based on this information, we decided that the Plan's rules for coverage of a progressive lens, polycarbonate lenses and anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to pay for a progressive lens (V2781), polycarbonate lenses (V2784) and anti-reflective coating (V2750) provided on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid, digital, binaural (V5261) provided February 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the hearing aids. You say that you would like the hearing aids covered. The Plan denied your request. The Plan says the hearing aids are not covered when provided out-of-network.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. 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.
We looked at the file and the Plan's rules. 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 hearing
aid, digital, binaural (V5261) provided February 15, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the $275 copayment charged for diagnostic services provided
on April 7, 2021.
You asked the Plan to waive this copayment. You say that you were not told the copayment would be this high.
The Plan denied your request. The Plan says this copayment was charged based on the services provided.
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 $275 for
outpatient diagnostic services. 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 $275 copayment charged for diagnostic services provided
on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered on August 20, 2020.
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 procedure code 99239 is not supported.
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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of 31 minutes or more of hospital discharge services spent on the enrollee. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge services rendered on August 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 29, 2020.

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.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgical services rendered on February 8, 2021.

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 procedure code 43239 is not supported.

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 43239 is esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple. 

We find that CPT code 43239 is not supported in the medical record. Specifically, there is no documetnation of an esophagogastroduodenoscopy with biopsy. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient surgical services rendered on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the bupivacaine hydrochloride injection provided on November 10, 2020.
You asked the Plan to pay for the injection, bupivacaine hydrochloride, 30 ml (S0020). You say that the Plan should pay this claim. The Plan denied your request. The Plan says S codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The requested code is not approved. Medicare does not cover S codes. Since this code is not covered by Medicare it cannot be approved. Based on this information, we decided that Medicare rules for coverage of the injection, bupivacaine hydrochloride, 30 ml (S0020) have not been met. Therefore, we decided that the Plan does not have to pay for the bupivacaine hydrochloride injection provided on November 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve Durolane. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.
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 Durolane. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found that this appeal considers the request for Durolane for the treatment of primary osteoarthritis of bilateral knees. The enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered or that the plan's required drugs 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy provided on February 16, 2021 and the prefabricated post and core provided on March 8, 2021.
You asked the Plan to pay for the endodontic therapy and prefabricated post and core. You say that you were told the dentist was in-network, but the Plan denied the services for being out-of-network. You say that this is not fair, and the Plan should pay. The Plan denied your request. The Plan says the services are not covered 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, the requested items or services are not among those covered under this benefit. Please note, the provider is in-network, but the services denied for being non-covered benefits. Therefore, we decided that the Plan does not have to pay for endodontic therapy provided on February 16, 2021 and the prefabricated post and core provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride provided on April 6, 2021.
You asked the Plan to pay for the topical application of fluoride. You say that you did not ask for the fluoride
treatment and do not think it was necessary. The Plan denied your request. The Plan says the service is not a
covered 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 pay for the
topical application of fluoride provided on April 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 11, 2021.
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 billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bariatric surgery (laparoscopic gastric sleeve) for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says there is no current BMI of 35 or more.
The Plan must follow Medicare rules. Medicare rules say that bariatric surgery is covered by Medicare in patients with a BMI of 35 of 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 pre-approve the surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records indicate a body mass index of 31.45 kg/m2. This is less than the criteria require for the requested surgery. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve bariatric surgery (laparoscopic gastric sleeve) for the enrollee
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 the stay 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and have been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). You have tolerated inpatient rehab services and continue to improve with daily skilled nursing and/or skilled therapy services. You could benefit from continued services at the current level of care. You have made slow progress with therapy, there is no indication that transfer to a SNF is required. You can continue to receive skilled rehab services at the current IRF or be stepped down to a lower level of care when appropriate. There are no services offered at a SNF that are not offered at an IRF. Admission to a SNF for inpatient skilled rehab services 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

Explanation of decision
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 a stroke in April 2021. You were transferred to skilled nursing then discharged to an assisted living facility on May 21, 2021. You have ongoing weakness. Medical conditions 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. You do require physical and
occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on March 3, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 services at issue in this appeal. 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 the services provided to you by an out-of-network provider on March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307, G0483) provided November 9, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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 codes 80307, & G0483 is not supported in the medical record. Specifically, the place of service on the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). 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 lab services (80307, G0483) provided November 9, 2020.