Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you require assistance regarding your wound care. The Plan denied your request. The Plan says that you do not have a daily skilled medical or therapy need.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87481, 87640, 87653, 87798, 87801) rendered by the out-of-network (OON) provider on April 7, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 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 laboratory services (87481, 87640, 87653, 87798, 87801) rendered by the out-of-network (OON) provider on April 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from January 25, 2021, through January 31, 2021.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for SNF services provided from January 25, 2021, through January 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 23, 2021 by a non-contracted 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 a non-contracted 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 referring provider 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 laboratory services provided on March 23, 2021 by a non-contracted provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87086, 87088) rendered by the out-of-network (OON) provider on December 3, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 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 laboratory services (87086, 87088) rendered by the out-of-network (OON) provider on December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for a diabetic eye exam (99214) provided on March 26, 2021.

You asked the Plan to hold you harmless for a diabetic eye exam. You say that you do not have money to the pay the bill. The Plan denied your request. The Plan says that a diabetic eye exam is not covered by the 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 will pay for outpatient doctor services for the diagnosis and treatment of diseases of the eye including annual eye exams for diabetic retinopathy. 

We looked at the file and the Plan's rules. The records show you have type 2 diabetes. The Plan contract confirms that an annual eye exam for diabetic retinopathy is covered. Based on this information, we decided that the Plan's rules for coverage of a diabetic eye exam have been met. Therefore, we decided that the Plan has to hold you harmless for a diabetic eye exam (99214) provided on March 26, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 20, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, feefor-
service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for laboratory services provided on October 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81201, 81317, 81406, 81407, 81408, 81432) provided February 17, 2021.

You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so one CPT code must be submitted for the panel. 

We looked at the file and Medicare rules. In this case, multiple unbundled CPT codes were billed for a genetic testing panel. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81201, 81317, 81406, 81407, 81408, 81432) provided February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (86141, 80061) provided on March 23, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for OON laboratory services. You say that you needed these services. The Plan denied your request. The Plan says these 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 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 laboratory services (86141, 80061) provided on March 23, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on March 1, 2021.

You asked the Plan to pay for an eye refraction. You say that you would appreciate the plan covering this refraction and future refraction's. The Plan denied your request. The Plan says you did not receive a routine eye exam on this date of service.

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 these services when it is performed as a routine eye exam.

We looked at the file and the Plan's rules. The records show an eye refraction was performed as part of a medical vision exam, and therefore is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on March 1, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for therapeutic exercises (97110), physical therapy re-evaluation (97164)
and therapeutic activities (97530) provided on February 4, 2021.

You asked the Plan to pay for the therapy services. You say that you would like reconsideration because these
services were billed correctly. The Plan denied your request. The Plan says that CPT codes 97164, 97530,
97110 are not approved by Medicare to be done in a high level place of treatment.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the Plan has failed to forward any citations or evidence as to why
these codes are not payable when billed with an Ambulatory Surgical Center Place of Service Code. It is the
burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so
we must find in your favor. Therefore, we decided that the Plan has to pay for therapeutic exercises (97110),
physical therapy re-evaluation (97164) and therapeutic activities (97530) provided on February 4, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for a power wheelchair provided on December 18, 2020.
You asked the Plan to pay for a power wheelchair. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for a power wheelchair provided on December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ophthalmology visit (92133, 92014) provided March 1, 2021.
You asked the Plan to waive the copayment for the ophthalmology visit. You say that glaucoma screenings are covered in full and there is a $25 specialist copay. The $40 is incorrectly applied. The Plan denied your request. The Plan says the correct cost-sharing was applied. The service did not include a glaucoma screening.
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 Medicare-covered eye exam services. You have been asked to pay a $40 copayment for the ophthalmology visit. The ophthalmology visit falls within the Medicare-covered eye exam services 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 an ophthalmology visit (92133, 92014) provided March 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic breast ultrasound, diagnostic mammography, and
diagnostic digital breast tomosynthesis provided on October 19, 2020.

You asked the Plan to pay for diagnostic breast ultrasound, diagnostic mammography, and diagnostic digital
breast tomosynthesis. The Plan denied your request. The Plan says Original Medicare would be responsible for
payment of all Medicare covered services related or unrelated to the member's terminal condition. The
Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of
election to the date of discharge or revocation.

During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to
the terminal illness until the first day of the month following the month in which hospice was revoked or
discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for diagnostic breast ultrasound, diagnostic mammography, and
diagnostic digital breast tomosynthesis provided on October 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a Zoster (shingles) vaccine (90750) provided on April 27,
2021.
You asked the Plan to pay for a shingles vaccine. You say that you called ahead to make sure this vaccine
would be covered. The Plan denied your request. The Plan says this vaccine is covered under your prescription
drug benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine.
The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine.
Therefore, we decided that the Plan does not have to pay for a Zoster (shingles) vaccine (90750) provided on
April 27, 2021.
Benefits for a shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (G0483, 80307) provided November 24, 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 coverage criteria has not been met.

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 G0483, & 80307 are 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 the lab services (G0483, 80307) provided November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on December 16, 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 there is no valid face-to-face examination in the documentation.

The Plan must follow Medicare rules. The rules say that an in-person, face-to-face interaction between the
beneficiary and their treating physician is required prior to prescribing durable medical equipment.

We looked at the file and Medicare rules. There is no valid face-to-face examination the submitted
documentation from the prescribing physician. 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
lumbar-sacral orthosis rendered on December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020) and spherocylinder lenses (V2103) provided on March 16, 2021.

You asked the Plan to pay for eyeglass frames and spherocylinder lenses. You say that you have no idea why the claim was denied. The Plan denied your request. The Plan says you purchased two pairs of eyeglasses and you are covered for one pair of eyeglasses per year. The Plan also says you have exhausted your benefit limit.

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 contracts says you have a $150 allowance once per year to use towards the purchase of one pair of standard eyeglasses. 

We looked at the file and the Plan's rules. The records show you purchased 2 pairs of eyeglasses on March 16, 2021. The EOC confirms you are covered for one pair of standard eyeglasses; therefore, the second pair of eyeglasses is not covered. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames and spherocylinder lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020) and spherocylinder lenses (V2103) provided on March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that the enrollee has significant urinary incontinence during the day and night. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.