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

We decided that the Plan does not have to pre-approve hearing aids from an out-of-network provider.
You asked the Plan to pre-approve out-of-network hearing aids. You say that you need a replacement hearing aid for a unit that was lost. You would like to go back to the provider where you originally received this pair, but they are out-of-network. You feel this provider carries higher quality hearing aids at a better cost. The Plan denied your request. The Plan says the out-of-network hearing aid allowance may only be used once every three years. You previously purchased hearing aids from an out-of-network provider on March 5, 2020, which is less than three calendar years before this request. Therefore, the out-of-network hearing aid benefits are exhausted at this time.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for out-of-network hearing aids only up to $500 and only once every three calendar years. We looked at the file and the Plan's rules. You previously purchased out-of-network hearing aids in 2020, which is less than three years ago. Based on this information, we decided that the Plan's rules for coverage of out-of-network hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmology services provided on August 3, 2021.
You asked the Plan to waive the copayment for ophthalmology services. You say that you disagree with the charges because this was a routine eye exam. 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 $40 copayment for specialist services. You have been asked to pay a $40 copayment for ophthalmology services. Ophthalmology services fall within the physician/practitioner services, including doctor's office visits 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 ophthalmology services provided on August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites - one surface, posterior (D2391) provided February 24, 2020.
You asked the Plan to pay for the fillings. You say that you need help covering this emergency dental work. The Plan denied your request. The Plan says this service is not covered under your benefits.
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 resin-based composites - one surface, posterior (D2391) provided February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two custom fabricated abutments (D6057 x2) and two implant supported crowns (D6066 x2).
You asked the Plan to pre-approve the custom fabricated abutments and implant supported crowns. You say that in order to correct the bite issues tooth #'s 20 and 21 need to be reduced beyond minor enameloplasty and require indirect restorations to correct the issue. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit 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 pre-approve two custom fabricated abutments (D6057 x2) and two implant supported crowns (D6066 x2).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower spinal canal for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the notes sent in referenced other areas of the body.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the enrollee has pertinent information in the provided records. However, there is no red flag present to warrant an immediate MRI. There is a referral for physical therapy, but the program has not been initiated. Absent a six week of conservative management in this enrollee with no red flags, the medical necessity of the MRI of the lumbar spine has not yet been established.
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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower spinal canal for the enrollee
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 the enrollee had surgery resulting in her right
leg being shorter, so she has been walking with discomfort for several years. 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.
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace.
Although orthotics may be appropriate, neither Medicare nor the Plan provides coverage of orthotics for the
enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit and pap smear to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit and pap smear. You say that you went to the recommended gynecologist but does not like the doctor. The Plan denied your request. The Plan says the provider is out-of-network.
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 the office visit and pap smear to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided on July 28, 2021.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you are being charged out-of-network charges when the provider is in-network. 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 $20 copayment for in-network outpatient rehabilitation services and a $55 copayment for out-of-network outpatient rehabilitation services.
You received outpatient rehabilitation services on July 28, 2021. The record shows that at the time services were received, the provider was out-of-network. Therefore, you are responsible to pay the $55 copayment. You have been asked to pay a $55 copayment for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 outpatient rehabilitation services provided on July 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MRI to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the MRI. You say that the enrollee requires the use of a sitting/standing and open MRI. You say the enrollee is unable to receive this service at an in-network facility. The Plan denied your request. The Plan says the provider is out-of-network
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 the MRI to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network surgeon.
You asked the Plan to pre-approve these services. You say that the treatment from in-Plan providers has fallen
short. The Plan denied your request. The Plan says the services are available from network providers.
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
a referral to an out-of-network surgeon
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a comprehensive eye examination provided on February 23, 2021.
You asked the Plan to waive the copayment for a comprehensive eye examination. The Plan denied your request. The Plan says the claim 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 Vision Care for a $40 copayment. You have been asked to pay a $40 copayment for a comprehensive eye examination. A comprehensive eye examination falls within the Vision Care benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a comprehensive eye examination provided on February 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on August 16, 2021.
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you feel that the stress test should be covered under your wellness exam. 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 $75 copayment for diagnostic radiology services. You received myocardial perfusion imaging on August 16, 2021. Myocardial perfusion imaging is considered a diagnostic service. Therefore, you are responsible to pay the $75 copayment.
You have been asked to pay a $75 copayment for myocardial perfusion imaging. Myocardial perfusion imaging falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for myocardial perfusion imaging provided on August 16, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional units of psychological and neuropsychological testing for the enrollee.
You asked the Plan to pre-approve the additional testing. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria require that the units for testing are within the established standards of practice.
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 additional testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on a review of the records, it appears that the provider is requesting an excessive amount of units beyond which is already approved. The enrollee has shown an impairment in functioning as documented. She has been showing difficulty with memory issues as outlined using the
interpretation. There was no documentation that justifies the extra amount of time in the testing and assessment. 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 additional testing have not been met. Therefore, we decided that the Plan does not have to pre-approve additional units of psychological and neuropsychological testing for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported crown (D6058) provided on September 7, 2021.
You asked the Plan to pay for the custom fabricated abutment (D6057) and abutment supported crown (D6058). You say that the only alternative was a removable partial bridge which would cost in excess of the $1,000 policy limit. You say that it would be appropriate and necessary for the Plan to pay the equivalent of such procedure. The Plan denied your request. The Plan says the services are not covered benefits.
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 custom fabricated abutment (D6057) and abutment supported crown (D6058) provided on September 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxygen equipment for the enrollee.
You asked the Plan to pre-approve the equipment. You say that this is medically necessary. The Plan denied your request. The Plan says this is being requested for a preventive and precautionary purpose.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 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 equipment. Our reviewer says that the requested equipment is not medically reasonable or necessary. Our physician reviewer found pulse oximetry on 11/24/2021 established a need for supplemental oxygen. A stationary concentrator and portable oxygen system is medically necessary, and these items have been approved.
The stationary compressed oxygen tank, for purposes of back-up oxygen source, is not medically necessary, and is not covered by Medicare. 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 equipment have not been met. Therefore, we decided that the Plan does not have to pre-approve oxygen equipment for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the chest x-ray services provided on November 15, 2020.
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says that there is no additional documentation supporting an additional study.
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 71045 is radiologic examination, chest, single view. We find that CPT code 71045 is supported in the medical record. The claim information shows that 2 units of code 71045 was billed. The remittance notices provided show that only 1 unit of service was billed. Based on this information, we decided that the Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay for the chest x-ray services provided on November 15, 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: Favorable

We decided that the Plan has to pay for an emergency room visit (99285) provided on May 19, 2021.
You asked the Plan to pay for emergency room visit 99285. You say that the records support this code. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because code 99285 is a procedure-to-procedure (PTP) edit column II code to column I code 99284 so cannot be separately paid without an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The Plan denied payment for code 99285 on the basis that code 99285 is a column II code to column I code 99284. However, we have confirmed that code 99285 is a column I code to column II code 99284. Therefore, the basis of the Plan's denial is incorrect. Based on the claim submitted, Medicare billing criteria have been met. Therefore, we decided that the Plan has to pay for an emergency room visit (99285) provided on May 19, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit received on October 5, 2021.
You asked the Plan to pay for the annual wellness visit. You say that you never paid for this service in the past. The Plan denied your request. The Plan says the services received exceed your benefit limit.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. The file shows that you previously received an annual wellness visit on August 12, 2021. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit received on October 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility services provided on April 1, 2021, through April 22, 2021.
You asked the Plan to pay for the skilled nursing facility services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an itemized bill has not been received.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing facility services have not been met. Specifically, the record does not include an itemized bill or UB-04 for the billed dates of service to verify if Medicare criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility services provided on April 1, 2021, through April 22, 2021.