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

We decided that the Plan does not have to pay for the progressive lens provided on April 1, 2021.

You asked the Plan to pay for the progressive lens. You say that the benefits indicate that progressive lenses are covered in full. The Plan denied your request. The Plan says covered eyeglasses after cataract surgery only includes standard frames and lenses as defined by Medicare.

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 only covers standard frames and lenses after cataract surgery. 

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 progressive lens have not been met. Therefore, we decided that the Plan does not have to pay for the progressive lens provided on April 1, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from October 3, 2020, to October 4, 2020.

You asked the Plan to waive the copayment for the emergency room visit. You say that this visit was behavioral related, and the copayment should be waived for 2020 because of the coronavirus. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 services at an in-network emergency room.

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. Please note, there is no provision in the contract which states a copayment would be waived because of the coronavirus. 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 the emergency room visit provided from October 3, 2020, to October 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an adjustable bed with flexible mattress and sales tax provided on October 5, 2020.

You asked the Plan to pay for these items. You say that you needed the bed to raise your head and legs. The Plan denied your request. The Plan says that Medicare does not cover adjustable beds.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for an adjustable bed with flexible mattress and sales tax provided on October 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for pontic - porcelain fused to high noble metal (D6240), retainer crown - porcelain fused to high noble metal (D6750), and a metal-ceramic retainer for a fixed partial denture (D6069) provided February 2, 2021.

You asked the Plan to pay for dental services. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says these services are not covered under the Plan's supplemental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for pontic - porcelain fused to high noble metal (D6240), retainer crown - porcelain fused to high noble metal (D6750), and a metal-ceramic retainer for a fixed partial denture (D6069) provided February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two removable prosthodontic procedures (D5899 x2) provided on May 10, 2021.
You asked the Plan to pay for the removable prosthodontic procedures. You say that these services that were provided were a new set of dentures because your old set and lost four teeth. The Plan denied your request. The Plan says this service is not a covered benefit under 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, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two removable prosthodontic procedures (D5899 x2) provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation represented by dental code D0150 and the panoramic radiographic image represented by dental code D0330 provided on May 3, 2021.

You asked the Plan to pay for dental codes D0150 and D0330. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D0150 and D0330 are covered once every three plan years. You received these services on February 7, 2019, which is less than three years ago.

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 the Plan's rules. The Plan contract says that dental codes D0150 and D0330 are covered once every three plan years. You received these services on February 7, 2019, which is less than three years ago. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation represented by dental code D0150 and the panoramic radiographic image represented by dental code D0330 provided on May 3, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for fluorescence in situ hybridization (FISH) testing provided on March 10, 2021.

You asked the Plan to pay for FISH testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this test is not a covered benefit for the diagnosis listed and was done for screening purposes.

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. This testing was ordered by an in-network provider. The file does not show that the plan provided notice that FISH testing would not be covered. Under Medicare rules, this means FISH testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for UroVysion fluorescence in situ hybridization (FISH) testing provided on March 10, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic radiology services provided by a
participating provider on March 25, 2021.

You asked the Plan to waive the copayment for diagnostic radiology services. You say that you have never had
a copayment for this before. 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 $110
copayment for outpatient diagnostic tests/diagnostic radiology services.

You have been asked to pay a $110 copayment for diagnostic radiology services. The correct copayment has
been applied to the services that were provided. Diagnostic radiology services fall within the outpatient
diagnostic tests/diagnostic radiology 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 diagnostic radiology services provided by a participating provider on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99233) provided February 18, 2021.

You asked the Plan to pay for the hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid primary diagnosis code.

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 99233 is not supported in the medical record. Specifically, diagnosis code I31.4 requires the underlying disease be listed first as the primary diagnosis. I31.4 was listed as the primary diagnosis. Based on this information, we decided that Medicare rules for coverage of the hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99233) provided February 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for podiatry surgery.

You asked the Plan to pre-approve the referral. You say that the Plan denied your request. The Plan says there are in-network providers available.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for podiatry surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on March 9, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you had your annual wellness visit
and you believed this visit was supposed to be free with no copayment. The Plan denied your request. The Plan
says you have been asked to pay the correct cost-sharing 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 $20
copayment for each Medicare-covered primary care doctor visit (including telehealth services, nationally
contracted walk-in clinic services, and urgently needed services).
You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The record shows you received other
services, such as ear wax removal, in addition to the annual wellness visit.
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 the office visit provided on March 9, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided October 19, 2020, to October 24, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee required an inpatient stay rather than an observation level of care. The Plan denied your request. The Plan says that the enrollee did not meet criteria for inpatient level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the emergency room on October 18, 2020, with weakness, decreased appetite and weight loss. He was found to be anemic due to blood loss. He was admitted and evaluated by Gastroenterology and underwent an upper endoscopy. The study showed the problem to be due to oozing from arterio-venous malformations. He was treated and his condition stabilized and improved, and he was discharged home when considered medically stable on October 24, 2020. The review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided October 19, 2020, to October 24, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy services to be provided by an out-of-network provider.
You asked the Plan to pre-approve medical nutrition therapy services. You say that you are hoping that these services will be approved, and that you can provide them. The Plan denied your request. The Plan says the enrollee does not meet the criteria for medical nutrition therapy and this provider is out-of-network with the Plan.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy services to be provided by an out-of-network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the OneTouch Ultra meter and test strips.

You asked the Plan to pre-approve the strips. You say that this is medically necessary. The Plan denied your request. The Plan says there has been no trial of a preferred blood glucose meter/test strip.

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 the strips. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided record does not indicate why the plan's preferred monitor and supplies are not appropriate. There is no indication as to why the requested brand is medically necessary, as defined by Medicare rules for the enrollee's clinical condition. The elements of the coverage rule 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 the strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the OneTouch Ultra meter and test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound care provided on April 21, 2021.

You asked the Plan to waive the copayment for the wound care. You say that you do not know the difference between office charges and hospital charges. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $290 copayment for each Medicare-covered in-network outpatient hospital facility visit.

You have been asked to pay a $290 copayment for the wound care. The wound care falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 the wound care provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on May 6, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that the doctor visit was the same day as your chemotherapy treatment The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $30 copayment for each Medicare-covered specialist visit (including surgery second opinion, telehealth services, and urgently needed services).

You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visit" benefit category. The record shows the specialist visit is considered a separate service.

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 the specialist office visit provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (G0283) and therapeutic procedure (97110) provided on May 3, 2021 and May 5, 2021.

You asked the Plan to pay for electrical stimulation (G0283) and therapeutic procedure (97110). You say that you are getting much needed relief from the chiropractor but cannot afford the full payment. The Plan denied your request. The Plan says the electrical stimulation and therapeutic procedures are not covered when provided by a chiropractor.

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 electrical stimulation (G0283) and therapeutic procedure (97110) provided on May 3, 2021 and May 5, 2021, or provide these services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).

You asked the Plan to pre-approve a pneumatic compression device. You say that you would like the reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker and commode seat purchased March 17, 2021.

You asked the Plan to pay for a walker and commode seat. You say that you would like these claims
reprocessed and approved for payment. The Plan denied your request. The Plan says these items were
purchased from a provider who does not participate with Medicare and who does not bill to insurance.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for a walker and commode seat purchased
March 17, 2021.