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

We decided that the Plan does not have to waive the coinsurance for the pembrolizumab injection provided on December 3, 2020,
You asked the Plan to waive the coinsurance for the pembrolizumab injection. You say that you were informed you wouldn't be responsible for any cost because it was administered at the infusion center. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B chemotherapy prescription drugs and Medicare Part B non-chemotherapy prescription drugs. You have been asked to pay $2,033.84, which is 20% of the allowed amount for the pembrolizumab injection. The allowed amount is $10,169.20 (20% x $10,169.20 = $2,033.84). The pembrolizumab injection falls within the "Medicare Part B prescription drugs" 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 the pembrolizumab injection provided on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services (97811x7, 97810x7, 97026x7, G0283x7) provided October 20, 2020 to December 15, 2020.
You asked the Plan to pay for the acupuncture services. You say that you checked on coverage of benefits and there was coverage of 100% with $10 copay for acupuncture (out of network). Please reconsider this denial. The Plan denied your request. The Plan says the services was rendered by non-covered provider as the provider is a licensed acupuncturist, not a physician. This provider also is not supervised by a physician, PA, NP or CNS.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the record does not show that the provider of the acupuncture services is a physician, PA, NP, or CNS. The service must be provided by a legally qualified physician practicing within the scope of their license. Therefore, we decided that the Plan does not have to pay for the acupuncture services (97811x7, 97810x7, 97026x7, G0283x7) provided October 20, 2020 to December 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the computerized corneal topography (92025) provided January 5, 2021.

You asked the Plan to pre-approve the corneal topography. You say that claim denied for experimental, however procedure was performed out of medical necessity to evaluate due to reported diagnosis.Please review and reconsider for payment. The Plan denied your request. The Plan says the clinical value and effectiveness of corneal topography in the setting of senile cataracts have not been demonstrated in the peer review literature.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the corneal topography have not been met. Therefore, we decided that the Plan does not have to pre-approve the computerized corneal topography (92025) provided January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on January 7, 2021.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says prior authorization was required but not obtained.
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 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 provided by an out-of-network provider on January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a diabetic shoe for a density insert (A5500) and a multiple density insert (A5512) provided on May 14, 2020.

You asked the Plan to pay for a diabetic shoe and an insert. You say that it had been over a year since you got your last pair of orthotics. The Plan denied your request. The Plan says the benefit has been exhausted for the calendar year.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan contract covers one pair of therapeutic shoes per calendar year for enrollees with severe diabetic foot disease. 

Based on review of the file, a prior set of therapeutic shoes and inserts was provided to you on February 3, 2020, fewer than 12 months prior to the date of service at issue in this case. Therefore, we decided that the Plan does not have to pay for a diabetic shoe for a density insert (A5500) and a multiple density insert (A5512) provided on May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00811) provided January 25, 2021.

You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary.The Plan denied your request. The Plan says this code is not eligible for separate payment.

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 code 00811 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, this code has a status indicator of "J" and there is no payment amount associated with it. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met.Therefore, we decided that the Plan does not have to pay for anesthesia services (00811) provided January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for the emergency department visit, moderately severe problem (99283) and drainage of abscess, cyst, or blood accumulation of dental bone (41800) provided December 14, 2020.

You asked the Plan to hold you harmless for the ER visit and drainage of abscess, cyst, or blood accumulation of dental bone. You say that you required emergency medical services which you expected to be covered by the Plan. The Plan denied your request. The Plan says that coverage of these services is excluded.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.

You were referred for the ER visit and drainage of abscess, cyst, or blood accumulation of dental bone by a contract provider. The file does not show that the Plan provided notice that the ER visit and drainage of abscess, cyst, or blood accumulation of dental bone would not be covered. Under Medicare rules, this means the ER visit and drainage of abscess, cyst, or blood accumulation of dental bone is considered approved by the Plan. The Plan did not submit medical records from the Plan contracted provider in this case. The Plan denial cannot be substantiated based on the information submitted for review. Therefore, we decided that the Plan has to hold you harmless for the emergency department visit, moderately severe problem (99283) and drainage of abscess, cyst, or blood accumulation of dental bone (41800) provided December 14, 2020.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on December 16, 2020.
You asked the Plan to reimburse you for the eyeglasses. You say that you did not know that this provider was not in-network and you do not have the internet. You say this provider is 15 minutes from your home and you were being very cautious of COVID-19. The Plan denied your request. The Plan says routine eyewear needs to be ordered through the Plan's vision provider.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when ordered through the Plan's vision provider. We looked at the file and the Plan's rules. The file shows that the eyeglasses were not ordered through the Plan's vision provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Fundus photography and fitting of contact lenses provided on December 31, 2020.
You asked the Plan to pay for the Fundus photography and fitting of contact lenses. You say that The Plan denied your request. The Plan says the Plan does not cover Fundus photography and fitting of contact lenses under the supplemental vision 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.
We looked at the file and the Plan's rules. The file shows that the Plan paid the correct amount for the eye exam based on the Plan's routine vision benefit. There is no coverage for Fundus photography and fitting of contact lenses in the Plan's routine vision benefit. Therefore, we decided that the Plan does not have to pay for Fundus photography and fitting of contact lenses provided on December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telephone evaluation provided on January 11, 2021.

You asked the Plan to waive the copayment for the telephone evaluation. You say that your saw your primary care physician for an annual physical but was charged for a telehealth visit. You say that the annual physical copayment is $0. The Plan denied your request. The Plan says the 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). The enrollee's contract with the Plan clearly says that enrollees must pay $0 for an annual physical. If you receive services that address a medical condition during the same office visit, you pay a $10 PCP office visit copayment. 

The enrollee has been asked to pay a $10 copayment for the telephone evaluation. The telephone evaluation falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that hypertensive disorder and anxiety were discussed during the visit. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the telephone evaluation provided on January 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 4 services performed by a qualified occupational therapist in the home health or hospice setting (G0152 x4).
You asked the Plan to pre-approve the services performed by a qualified occupational therapist. You say that you would like these services to be approved for coverage. The Plan denied your request. The Plan says the request for 4 home health occupational therapist services does not meet medical necessity criteria.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 performed by a qualified occupational therapist. Our reviewer says that the services performed by a qualified occupational therapist are not medically reasonable and necessary.
Our physician reviewer found based on the medical records provided there is no documentation that that skilled occupational therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. Our reviewer also found that the provided records document a prior occupational therapy evaluation from March 22, 2021 indicating you had reached maximum potential, were discharged from services at that time, and no records document a new need for occupational therapy services at this time. 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 performed by a qualified occupational therapist have not been met. Therefore, we decided that the Plan does not have to pre-approve the 4 services performed by a qualified occupational therapist in the home health or hospice setting (G0152 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete lower denture (D5120), and an unspecified preventive procedure (D1999) provided on December 7, 2020.

You asked the Plan to pay for a complete lower denture, and an unspecified preventive procedure. You say that you want the Plan to pay for the services at issue. The Plan denied your request. The Plan says the complete lower denture is a covered benefit, but you have exceeded the frequency limit of one every 5 years. The unspecified preventive procedure 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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a complete lower denture, and an unspecified preventive procedure have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on October 30, 2019. Additionally, unspecified preventive procedure is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a complete lower denture (D5120), and an unspecified preventive procedure (D1999) provided on December 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for established patient home visit services (99348) provided on September 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the home visit. You say that these visits are not pre-scheduled, therefore an authorization was not obtained prior to the services provided. Therefore, you are appealing based on medical necessity. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 established patient home visit services (99348) provided on September 24, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility visit (99309) provided on December 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility visit. You say that your rendering provider is eligible to provide service to Medicare beneficiaries and had been paid by Medicare for previous services. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 subsequent nursing facility visit (99309) provided on December 21, 2020 by an out of network (OON) provider.
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 these services are medically necessary.
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. There is no
evidence that the enrollee requires services that are not currently available. As LTACHs and acute care
hospitals (ACH) are licensed to provide the same level of care, there is no advantage in transferring the enrollee
to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The
enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99213) individual psychotherapy (90833) provided on February 22, 2021 to March 4, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the office visits. You say that you saw your psychotherapist on October 12, 2020 and January 18, 2021. The bills from the therapist are documented in the attached receipts. The Plan denied your request. The Plan says the provider is not a certified Medicare participating provider.
The Plan must follow Medicare rules. Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can receive your care from either a network provider or an out-of-network provider. The requested provider in this case is not certified as a Medicare participating provider. 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 outpatient office visit (99213) individual psychotherapy (90833) provided on February 22, 2021 to March 4, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the complete denture - maxillary (D5110) and mandibular partial denture - flexible base (including any clasps, rests and teeth) (D5226) provided November 4, 2020.

You asked the Plan to provide additional payment for the dentures. You say that you were told the provider was in-network and believe you were charged too much. The Plan denied your request. The Plan says the claim has been reprocessed at an in-network rate and the Plan has paid up to your $2,500 annual dental maximum therefore, no additional payment is due.

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 dentures up to the annual maximum amount of $2,500. 

We looked at the file and Medicare rules. The Plan has provided documentation showing that the claim was paid up to your $2,500 annual maximum amount. Based on this information, we decided that the Plan does not have to provide additional payment for the complete denture - maxillary (D5110) and mandibular partial denture - flexible base (including any clasps, rests and teeth) (D5226) provided November 4, 2020.