Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851), suspension sleeve (L2397), ankle foot orthosis (L1971), foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf (L3170), neuromuscular stimulator (E0745) and electrical stimulator supplies, 2 lead, per month (A4595) provided on November 30, 2020.
You asked the Plan to pay for knee orthosis and suspension sleeve, ankle foot orthosis and prefabricated foot, plastic, silicone or equal heel stabilizer, neuromuscular stimulator and electrical stimulator supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says there is insufficient documentation to establish the medical necessity of the items requested.
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 knee orthosis and suspension sleeve, ankle foot orthosis and prefabricated foot, plastic, silicone or equal heel stabilizer, neuromuscular stimulator and electrical stimulator supplies. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the records provided do not credibly establish an objective assessment of the enrollee in order to determine the medical necessity and reasonableness of the requested services, and therefore, the elements of the coverage rules are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee orthosis and suspension sleeve, ankle foot orthosis and prefabricated foot, plastic, silicone or equal heel stabilizer, neuromuscular stimulator and electrical stimulator supplies have not been met. Specifically, there is insufficient documentation indicating the medical necessity of these items. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851), suspension sleeve (L2397), ankle foot orthosis (L1971), foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf (L3170), neuromuscular stimulator (E0745) and electrical stimulator supplies, 2 lead, per month (A4595) provided on November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (CPT code 99233) provided to the enrollee from December 7, 2019, through December 8, 2019, by an out-of-network provider.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the claims were not received within the twelve (12) month period.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until December 29, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (CPT code 99233) provided to the enrollee from December 7, 2019, through December 8, 2019, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 85610, P9604, 36415) provided to the enrollee on January 11, 2021, by a non-participating provider.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.

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 laboratory services (CPT code(s): 85610, P9604, 36415) provided to the enrollee on January 11, 2021, by a non-participating provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room visit (99283) provided December 14, 2020 to December 15, 2020.
You asked the Plan to waive the copayment for the Emergency Room visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the Emergency Room visit. the Emergency Room visit falls 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 an Emergency Room visit (99283) provided December 14, 2020 to December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite on tooth #31 provided on January
22, 2021.

You asked the Plan to pay for the resin-based composite. You say that this restoration was necessary. The Plan
denied your request. The Plan says this service exceeds the frequency limitation outlined in 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, coverage for the replacement of
restorations is provided only after a 2-year period has elapsed. The record shows that you received a resinbased
composite on tooth #31 on August 27, 2019, and your restorations benefit for tooth #31 has been
exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite on tooth #31
provided on January 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostatic arterial embolization.

You asked the Plan to pre-approve 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 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found you have a diagnosis of benign
prostatic hypertrophy (BPH) with lower urinary tract symptoms. The requested procedure is considered
experimental/investigational in nature and is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve prostatic arterial embolization.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient surgery provided on November 19, 2020 by an out of network (OON) provider.

You asked the Plan to pay for an outpatient surgery. You say that you were unaware that prior authorization was required for this CPT code. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available for these services.

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 an outpatient surgery provided on November 19, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on March 8, 2021.

You asked the Plan to waive the copayment for lab work. You say that the lab work was provided during an annual wellness exam. You say that you should not have to pay for this. The Plan denied your request. The Plan says the correct copayment has been applied.

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 outpatient diagnostic tests/lab services.

You have been asked to pay a $10 copayment for lab work. When additional services were provided during an annual wellness exam, additional copayments are applied; therefore, the correct copayment has been applied.

Lab work falls within the outpatient diagnostic tests/lab 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 lab work provided by a participating provider on March 8, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study.
You asked the Plan to pre-approve a sleep study. The Plan denied your request. The Plan says a sleep study is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that sleep studies are covered for the indications established in the applicable LCD> 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 sleep study. Our reviewer says that the requested sleep study is not medically reasonable and necessary. Our physician reviewer found that there is no clinical rationale for the requested sleep study. The medical records do not show that the enrollee has nocturnal snoring, apnea or nocturnal coughing/choking/gasping. In addition, the enrollee denies morning headaches or daytime sleepiness. Specifically, there is no evidence that the enrollee has habitual loud snoring, choking or gasping during sleep, BMI greater than or equal to 30, neck circumference greater than 17 in. (men) or greater than 16 in. (women), sleep related bruxism, cognitive deficits such as inattention or memory,
unexplained nocturnal reflux, apneas or hypoxemia during procedures requiring anesthesia, or morning headaches. 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 sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for removal and replacement of dual lead permanent pacemaker pulse generator (CPT code 33228) provided on February 6, 2020, at the outpatient department of the medical center.

You asked the Plan to waive the copayment for the surgery. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file show that you had a surgery on February 6, 2020, at the outpatient department of the facility. You were asked to pay a $175 copayment for the surgical services. Your 2020 EOC states that enrollees must pay a $175 copayment for surgery services - outpatient hospital. 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 removal and replacement of dual lead permanent pacemaker pulse generator (CPT code 33228) provided on February 6, 2020, at the outpatient department of the medical center.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a visual field examination (92083), a medical eye examination (92014), an eye examination with photographs (92250), and scanning computerized ophthalmic diagnostic imaging (92133) provided on October 30, 2020.

You asked the Plan to pay for a visual field examination, a medical eye examination, an eye examination with photographs, and scanning computerized ophthalmic diagnostic imaging. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.

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 routine vision care when the Plan's network providers are utilized. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of a visual field examination, a medical eye examination, an eye examination with photographs, and scanning computerized ophthalmic diagnostic imaging have not been met. Specifically, services were provided by an out-of-network provider. The Plan has contracted providers available to provide these services. 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 a visual field examination (92083), a medical eye examination (92014), an eye examination with photographs (92250), and scanning computerized ophthalmic diagnostic imaging (92133) provided on October 30, 2020.
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.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated at a lower level of care.

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 patient does not require treatment by multiple therapies and an intensive rehabilitation therapy program. While the patient does require physical and occupational therapy, there is no documented need for an intensive rehabilitation program.

Medically necessary services can be provided in a different 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 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the complete denture - maxillary (D5110), and the complete denture - mandibular (D5120), for which the impressions were taken on November 30, 2020.

You asked the Plan to pay an additional amount for the complete maxillary and mandibular dentures. You say that the dental provider submitted a false claim on November 30, 2020. The Plan denied your request. The Plan says the denture impressions were taken on November 30, 2020. Claims for any type of prosthesis are submitted on the date the impressions are taken.

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. The Plan covers the complete maxillary and mandibular dentures when the services are medically necessary and reasonable.

We looked at the file, and Medicare rules. Clinical charts submitted by the provider for this claim indicate you were seen in this provider's office on this date of service and received denture impressions. Claims for any type of prosthesis are submitted on the date the impressions are taken. The Plan has submitted evidence that the requested items have been covered up to your $2,500 benefit maximum. You are responsible for any amount billed above your annual $2,500 benefit allowance. Based on this information, we decided that the Plan has provided coverage in accordance with the Plan contract. Therefore, we decided that the Plan does not have to pay an additional amount for the complete denture - maxillary (D5110), and the complete denture - mandibular (D5120), for which the impressions were taken on November 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of swallowing dysfunction and/or oral function for feeding coded 92526 provided from November 2, 2020 to November 6, 2020.

You asked the Plan to pay for the treatment of swallowing dysfunction and/or oral function for feeding. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 92526 is treatment of swallowing dysfunction and/or oral function for feeding.

We find that CPT code 92526 is not supported in the medical record. Specifically, the claim was not submitted with the required modifier to process and pay claim, which caused the claim to deny. claim was billed with 440 Rev Code for speech-language pathology without the appropriate modifier. Per Medicare guidelines a GN modifier is required. Based on this information, we decided that Medicare rules for coverage of the treatment of swallowing dysfunction and/or oral function for feeding have not been met. Therefore, we decided that the Plan does not have to pay for the treatment of swallowing dysfunction and/or oral function for feeding coded 92526 provided from November 2, 2020 to November 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a wheelchair provided by a participating provider on November 2, 2020, to March 2, 2021.

You asked the Plan to waive the coinsurance for a wheelchair. You say that you had issues with the wheelchair the whole time. You say that you do not agree with this coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been applied.

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 20% coinsurance for durable medical equipment/in-network. 

You have been asked to pay a 20% coinsurance of the allowed amount for a wheelchair. The total allowed amount is $846.76. The total amount you are being asked to pay is $169.34 ($846.76 x 20% = $169.34). A wheelchair falls within the durable medical equipment/in-network 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 coinsurance for a wheelchair provided by a participating provider on November 2, 2020, to March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam (non-routine) with photography (92250) on January 12, 2021.

You asked the Plan to waive the copayment for an eye exam with photography. You say that your Plan contract states you pay any amount over $40 for a routine exam with refraction/dilation as necessary. The Plan denied your request. The Plan says the correct copayment was applied.

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 a specialist's office visit for Medicare-covered vision services. 

You have been asked to pay a $40 copayment for an eye exam with photography. An eye exam with photography 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 waive the copayment for an eye exam (non-routine) with photography (92250) on January 12, 2021.