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

We decided that the Plan does not have to pay for an eye refraction (92015) provided on December 16, 2020.

You asked the Plan to pay for the eye refraction. You say that this should be covered by your plan, as eye
refractions are covered. The Plan denied your request. The Plan says only routine refractions for eyeglasses can
be covered. The refraction was provided as part of an ophthalmological medical examination and evaluation
and not as part of a routine vision check. Therefore, it cannot be covered.

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 they are performed as part of a routine exam to determine
changes in your vision and/or the need for eyeglasses or contact lenses.

We looked at the file and the Plan's rules. The refraction was provided alongside a medical eye exam. Based on
this information, we decided that the Plan's rules for coverage of the eye refraction have not been met.
Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on December
16, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on September 22, 2020.

You asked the Plan to waive the copayment for emergency care. You say that you thought that you would receive advanced imaging services but after waiting hours you were discharged and told to see a specialist. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care. 

You have been asked to pay a $90 copayment for emergency care. Emergency care 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 emergency care provided on September 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 28, 2019.

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 codes 80157, 80177, 80201, 80162, 80159 and 80173 are not covered.

The Plan must follow Medicare rules. The rules say that testing to confirm that a urine specimen is
unadulterated is an internal control process that is not separately reportable.

We looked at the file and Medicare rules. The file shows that the tests at issue were urine specimens utilized for
drug testing. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on
October 28, 2019.
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 the enrollee is not safe to go home in his condition. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require - or be able to tolerate - 15 hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care such as skilled nursing facility or sub-acute rehabilitation. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecfidera capsules.

You asked the Plan to pre-approve Tecfidera capsules. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Tecfidera capsules are not covered under the enrollee's Medicare Part B benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tecfidera capsules. 

Benefits for Tecfidera capsules 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), the cone beam CT (D0367), the removal of torus mandibularis (D7473 x 2), the therapeutic parenteral drug (D9612), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223 x 5), and the evaluation for moderate sedation (D9219) provided from February 21, 2020, to October 30, 2020.

You asked the Plan to reimburse you for the dental services. You say that this work was performed by an oral surgeon. You say that it was a physical necessity. You also say that it was not a dental issue. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services performed by a dentist who has opted out of Medicare.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, dental service performed by a provider who has opted out of Medicare are not covered. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), the cone beam CT (D0367), the removal of torus mandibularis (D7473 x 2), the therapeutic parenteral drug (D9612), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223 x 5), and the evaluation for moderate sedation (D9219) provided from February 21, 2020, to 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 the services are medically necessary. The Plan denied your request. The Plan says coverage criteria is not met.

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 there is not a reasonable expectation that this patient 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for telehealth services provided by a participating provider on January 15, 2021.

You asked the Plan to waive the copayment for telehealth services. You say that you do not feel like you should have to pay for this because it was a virtual visit. 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 $15 copayment for outpatient rehabilitation services/in-network. 

You have been asked to pay a $15 copayment for telehealth services. Telehealth services fall within the outpatient rehabilitation services/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 copayment for telehealth services provided by a participating provider on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the glasses (V2020, V2781, V2200) purchased on December
23, 2020.

You asked the Plan to pay for the glasses. You say that you were told you were eligible for new eyewear every
two years, and two years is a long time to remember an exact date of purchase. You feel that an exception
should be made because the dates are so close, and you would not have received the reimbursement check for
the glasses until after the 2-year date anyway. The Plan denied your request. The Plan says routine eyewear can
only be covered up to $100 every two years. This benefit is administered on a rolling calendar year since your
last date of service. The Plan paid for your last pair of glasses, which were provided on December 27, 2018.
You were not eligible for a new pair until December 27, 2020.

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 up to $100 for routine eyewear every two years from the last date of service.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the glasses have not been met. Therefore, we decided that the Plan does not have to pay for the
glasses (V2020, V2781, V2200) purchased on December 23, 2020.

Your complaint that the Plan should make an exception in your case because the purchase was made only a few
days before your new eligibility period is not a valid appeal for medical coverage. This part of your complaint
is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these
types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 21, 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 codes 80157 and 80177 are 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 80157 is assay of carbamazepine; free. The definition of
code 80177 is quantitative drug screen, levetiracetam.

We find that CPT codes 80157 and 80177 are not supported in the medical record. Specifically, the records
show that the testing was performed on urine samples and not blood samples. 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 laboratory services rendered on October 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on January 23, 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 71045 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 71045 and 71100. Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 71100. Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on January 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 28, 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 testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased on November 9, 2019.

You asked the Plan to pay for the eyeglasses. You say that you had submitted your first reimbursement request
before a year had passed, but it was denied because it did not include proof of payment. You feel the Plan
should use the initial request date and process the claim. The Plan denied your request. The Plan says that when
you purchase prescription eyewear out-of-pocket, a request for reimbursement, including a copy of your receipt
showing proof of payment, should be filed with our plan. This information was not submitted within a year
from the date of purchase.

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 eyeglasses was not filed until November 23, 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 the eyeglasses purchased on November 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on September 23, 2020.
You asked the Plan to pay for an office visit. You say that this should be covered. The Plan denied your request. The Plan says this cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of B is used for codes that are not recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x). We looked at the file and Medicare rules. The service at issue was billed on a bill type of 137. Code 99213 has a status indicator of B and is not recognized by OPPS on this bill type. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on September 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator provided on November 19, 2020 and December 19, 2020.
You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that you only have the portable now. You say that you returned the equipment, and they are still billing. 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-covered durable medical equipment and related supplies. You have been asked to pay a total of $54.70 for the oxygen concentrator.
Date of Service                           Service                   Allowed Amount       Coinsurance            Member Liability
November 19, 2020           Oxygen Concentrator             $136.77                    20%                        $27.35
December 19, 2020          Oxygen Concentrator             $136.77                    20%                        $27.35
TOTAL:                                                                                                                                     $54.70
The oxygen concentrator falls within the "Durable medical equipment (DME) and related supplies" 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 oxygen concentrator provided on November 19, 2020 and December 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 20, 2020 to November 6, 2020 by an out of network (OON) provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided on October 20, 2020 to November 6, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 22, 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 physician order.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. 

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation (G0283) provided from
September 14, 2020, through October 12, 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 these services are not a covered benefit under
your contractual policy or by Medicare.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.

The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for the electrical stimulation (G0283) provided from September 14, 2020,
through October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered from January 17, 20212 to January 20, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid primary diagnosis code. 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 critical care services rendered from January 17, 20212 to January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS) unit.

You asked the Plan to pre-approve a TENS unit. You say that this device is medically necessary. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that in order for a TENS device to be covered for chronic pain, the pain must have been present for at least 3 months. 

We looked at the file and Medicare rules. The medical records submitted do not provide evidence that the chronic shoulder pain has lasted for at least 3 months. Based on this information, we decided that Medicare rules for coverage of a TENS unit have not been met. Therefore, we decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS) unit.