Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refractions (92015) provided June 15, 2021. 
 
You asked the Plan to pay for the eye refractions. You say that the services were medically necessary and 
should be covered. The Plan denied your request. The Plan says out-of-network vision services are non-
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 obtained from plan contracted providers. 
 
We looked at the file and the Plan's rules. The services were not obtained from network providers. Based on 
this information, we decided that the Plan's rules for coverage of the eye refractions have not been met. 
Therefore, we decided that the Plan does not have to pay for eye refractions (92015) provided June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for medical services received in Hong Kong from April 6, 2020, to December 29, 2020.
You asked the Plan to pay for medical services. You say that while in Hong Kong you started to develop several painful medical symptoms and decided to seek treatment before it got any worse. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because these were various routine medical visits that were not urgent or emergent.
The Plan follows Medicare rules. Medicare only covers services provided outside of the United State and its territories under certain specific circumstances. These services do not fall under any of the circumstances for which Medicare may cover out-of-country services. However, the Plan also has a worldwide coverage benefit that goes beyond Medicare coverage. For that reason, the Plan's rules apply to this case. The Plan covers worldwide services that would be classified as emergency, urgently needed, or post-stabilization care had they been provided in the United States.
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 medical services. Our reviewer says that these services meet the criteria for coverage. Our physician reviewer found you saw a provider in Hong Kong for evaluation and treatment of hypertension and issues related to polyarteritis nodosa. You submitted receipts for payment. You could not have reasonably foreseen requiring these services prior to leaving the Plan's service area and the United States. The care provided to you was medically necessary. It would not have been medically reasonable to delay the services until you returned to the Plan's service area (or up to 6 months).
We looked at this physician's review, the file, the Plan's rules, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of medical services have been met. Therefore, we decided that the Plan has to pay for medical services received in Hong Kong from April 6, 2020, to December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an established patient office or other outpatient visit (99214) and the coinsurance for an injection of methylprednisolone 40 mg (J1030) provided by an in-network provider on July 7, 2021.
You asked the Plan to waive the copayment for an office visit and the coinsurance for an injection. You say that you were surprised by this bill and cannot afford the payment. The Plan denied your request. The Plan says the claim was processed 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 a $50 copayment for Physician/Practitioner Services, Including Doctor's Office Visits and a 20% coinsurance for Medicare Part B Prescription Drugs.
You have been asked to pay a $50 copayment for an in-network office visit. An office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits. You have also been asked to pay a 20% coinsurance for an injection (Allowed Amount = $11.10  20% = $2.22). Injections that are not self-administered and are provided while getting physician services fall under 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 copayment for an established patient office or other outpatient visit (99214) and the coinsurance for an injection of methylprednisolone 40 mg (J1030) provided by an in-network provider on July 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary.
The Plan denied your request. The Plan says the rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found while there are identifiable skilled nursing
service needs, these services are not required on a daily basis. In addition, there are no identifiable skilled
therapy service needs. In conclusion, you do not meet severity of illness or intensity of service criteria for an
inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the therapy services coded 97530, 97110, 97164, and 99350. We decided that the Plan does not have to pay for the home health aide services coded S9122 and the home nursing care services coded S9124.
You asked the Plan to pay for the home health aide services coded S9122, the home nursing care services coded S9124, the home visit coded 99350, and the therapy services coded 97530, 97110, 97164, and 99350 provided from January 4, 2021 to April 16, 2021. You say that you would like the plan to reconsider their denial. The Plan says that the services are not payable as billed.
We decided that the Plan has to pay for the therapy services coded 97530, 97110, 97164, and 99350.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the Plan states that these services are being denied due to "1108- multiple or concurrent procedure rules, 191- records do not support service billed, 0807- unbundle service, and 1031- code not appropriate for service billed. The Plan does not specify why these services are denied. The documentation does not support that the services billed are multiple or concurrent procedure rules, the documentation does not support why the services billed are not supported, how these services are unbundled, or how the code is not appropriate for the services billed. Therefore, we decided that the Plan has to pay for the therapy services coded 97530, 97110, 97164, and 99350.
We also decided that the Plan does not have to pay for the home health aide services coded S9122 and the home nursing care services coded S9124.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT codes S9122 and S9124 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home health aide services and the home nursing care services have not been met. Therefore, we decided that the Plan does not have to pay for the home health aide services coded S9122 and the home nursing care services coded S9124.
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 pay additionally for the dental extractions provided on May 25, 
2021. 
 
You asked the Plan to pay additionally for the dental extractions. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says non-Medicare covered dental services are 
not eligible for coverage above the $750 enhanced benefit limit under the Plan's supplemental dental benefit. 
The Plan has paid the enhanced benefit of $750 for the 2021 benefit year. 
 
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, the Plan's contract and Medicare rules. The Plan's contract says non-Medicare covered 
dental services are not eligible for coverage above the $750 enhanced benefit limit under the Plan's 
supplemental dental benefit. The Plan has paid the enhanced benefit of $750 for the 2021 benefit year. You are 
responsible for any amount over this limit. Therefore, we decided that the Plan does not have to pay 
additionally for the dental extractions provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the trigger point injection procedure you had at an outpatient hospital facility on June 2, 2021.
You asked the Plan to waive the copayment for the trigger point injection procedure. You say that this was not done in a treatment room, so you believe an error was made. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this procedure ($316.66) is less than your copayment obligation, you are responsible for the full allowed amount. The Plan also says that you have received similar services at this same location in the past and had the same cost sharing 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 on page 4-38 for outpatient surgery or other services at a hospital outpatient facility.
You have been asked to pay on page 4-38 for the trigger point injection procedure. The facility where you received these services is considered an outpatient hospital facility. That is why the trigger point injection procedure falls within the outpatient surgery or other services at a hospital outpatient facility 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 trigger point injection procedure you had at an outpatient hospital facility on June 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for mammogram services (77067 and 77063) provided February 
11, 2020. 
 
You asked the Plan to pay for the mammogram services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the codes billed are mutually exclusive to other codes billed on the 
same dates of service. 
 
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, we have confirmed that codes 
77067 and 77063 share a bundled relationship with codes 77066 and 77062.  
 
This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
mammogram services (77067 and 77063) provided February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician office specialist visit services provided on July 
12, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician office specialist visit services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says no prior authorization was 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. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the physician office specialist visit services provided on July 12, 
2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 home health skilled nursing visits.
You asked the Plan to pre-approve 4 home health skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 4 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 home health skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0330, D0220, D0150) provided April 27, 2021 to May 6, 2021.
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says the dental services provided are not covered under your dental 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 dental services (D0330, D0220, D0150) provided April 27, 2021 to May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by an opt-out of Medicare 
provider. 
 
You asked the Plan to pay for the dental services provided by an opt-out of Medicare provider. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
provider has opted-out of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental 
services provided by an opt-out of Medicare provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 19, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are 
medically necessary. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings 
identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a deep cleaning provided by a Periodontist.
You asked the Plan to pre-approve a deep cleaning provided by a Periodontist. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental services are not covered under the Plan's supplemental dental benefit unless provided by a participating general dentist.
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 services are not covered when provided by a Periodontist. Therefore, we decided that the Plan does not have to pre-approve a deep cleaning provided by a Periodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam computed tomography (CT) capture and interpretation (D0364) provided on April 27, 2021.
You asked the Plan to pay for a cone beam CT capture and interpretation. You say that you called the Plan prior to your appointment and was told that the services were covered. The Plan denied your request. The Plan says the service at issue 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 Plans 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 a cone beam computed tomography (CT) capture and interpretation (D0364) provided on April 27, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for a podiatry visit received on February 11, 
2021. 
 
You asked the Plan to adjust the copayment for the visit. You say that you were unaware that the provider was 
out-of-network. The Plan denied your request. The Plan says the plan has no recourse for incorrect information 
given by a non-contracted provider. 
 
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 $60 
copayment for out-of-network podiatry services.  
 
You have been asked to pay a $60 copayment for the visit. The visit falls within the out-of-network podiatry 
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 adjust the copayment for a podiatry visit received on 
February 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you disagree with the plan's denial. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
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 follows these same rules.   
 
Review of the file shows that no medical records were provided to the Plan. This means that the records do not 
support that you suffer from diabetic foot disease or that you wear a leg brace. Although orthotics may be 
appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, 
we decided that the Plan does not have to pre-approve foot orthotics.