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

We decided that the Plan does not have to pay for the eyeglasses (V2020, V2781, V2750) purchased on May 18, 2021.
You asked the Plan to pay for the eyeglasses. You say that this is an in-network provider and you should be reimbursed the full $200 annual allowance. The Plan denied your request. The Plan says this provider is not part of the Plan's vision network. Routine vision care received out of the Plan's routine vision network are not 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 received from a provider in the Plan's vision network. We looked at the file and the Plan's rules. The provider appears to be part of the Plan's medical network, but not part of the Plan's routine vision care network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2781, V2750) purchased on May 18, 2021.
Your complaint about potential confusion regarding the Plan's medical network and the Plan's routine vision network 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection (J2704) and anesthesia (00731) provided on April 15, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an injection and anesthesia. You say that this was provided in connection to in-network services. The Plan denied your request. The Plan says the surgery this was provided with was also 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 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 an injection (J2704) and anesthesia (00731) provided on April 15, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an expanded pharmacogenomic panel provided to the
enrollee on May 19, 2021.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says this should have been reported with CPT 81479.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay
for an expanded pharmacogenomic panel provided to the enrollee on May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing provided on May 19, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M are non-covered for CxBladder testing. We looked at the file and Medicare rules. The requested CxBladder testing was billed with code 0013M. This code is not covered for CxBladder testing. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing provided on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (20936) provided on May 4, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is bundled service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Code 20936 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for this service. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (20936) provided on May 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a catheter placement (36000, 77001) performed March 8,
2021.

You asked the Plan to pay for the catheter placement. You say that the services were medically necessary. The
Plan denied your request. The Plan says unbundled services are not eligible for payment.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. CPT
code 36000 has a status of "B" per the National Physician Fee Schedule. Payment for this service is always
bundled with another service. CPT code 77001 shares a bundled relationship with CPT code 37248 which was
also billed. 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 a catheter placement (36000, 77001) performed March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the polycarbonate lenses and tint provided on August 4, 2021.

You asked the Plan to pay for the polycarbonate lenses and tint. You say that you broke your glasses and need a new pair so you can see. You say that if the type of glasses you selected are not covered you want to know your options. The Plan denied your request. The Plan says enhanced services are not covered under your vision benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the polycarbonate lenses and tint have not been met. Specifically, lens upgrades are not covered. Therefore, we decided that the Plan does not have to pay for the polycarbonate lenses and tint provided on August 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the head, a magnetic resonance angiography (MRA) of the blood vessels in your neck, and an MRA of the blood vessels in your brain.
You asked the Plan to pre-approve an MRI of the head, an MRA of the blood vessels in your neck, and an MRA of the blood vessels in your brain. 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. 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 an MRI of the head, an MRA of the blood vessels in your neck, and an MRA of the blood vessels in your brain. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the head, an MRA of the blood vessels in your neck, and an MRA of the blood vessels in your brain have not been met. Therefore, we decided that the Plan does not have to pre-
approve a magnetic resonance imaging (MRI) of the head, a magnetic resonance angiography (MRA) of the blood vessels in your neck, and an MRA of the blood vessels in your brain
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 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 the enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does 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 skilled nursing facility (SNF) care
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental cleaning (D1110), periodic oral exam (D0120), core buildup procedure (D2950), provisional crown (D2799), unspecified adjunctive procedure (D9999), porcelain/ceramic crown (D2740) and filling (D2331) provided between May 10, 2021, and June 30, 2021.
You asked the Plan to pay for the dental services. You say that these services were medically necessary, and you expect to be reimbursed for the cost of this care. The Plan denied your request. The Plan says the provider in question does not participate with Original Medicare. Dental care must be received by a licensed dental provider who has not opted out of Original Medicare in order to be covered. Therefore, payment will not be made.
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. You may see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. If you use a provider that has opted out of Medicare, you will not receive reimbursement. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from providers who do not participate in Original Medicare will not be covered. The provider in question does not participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for a dental cleaning (D1110), periodic oral exam (D0120), core buildup procedure (D2950), provisional crown (D2799), unspecified adjunctive procedure (D9999), porcelain/ceramic crown (D2740) and filling (D2331) provided between May 10, 2021, and June 30, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the anesthesia services rendered on July 30, 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 that procedure code 00731 was not billed with an appropriate diagnosis code.

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. The Plan states that procedure code 00731 (anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified) was not billed with an appropriate diagnosis code per the Local Coverage Article (LCA); however, there is no binding LCA for the state of Florida where the services were performed. The Plan has not provided any documentation to support that the services are not payable as billed. Therefore, we decided that the Plan has to pay for the anesthesia services rendered on July 30, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device (wireless pulmonary artery pressure sensor).
You asked the Plan to pre-approve the CardioMEMS device. You say that the service is medically necessary. The Plan denied your request. The Plan says the device is not shown to be medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. At issue is whether a CardioMEMS device for the enrollee is a covered service under Medicare rules. In the absence of a national or local coverage determination the Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k), defines medically necessary and reasonable services. The CardioMEMS HF System is indicated for wirelessly measuring and monitoring pulmonary artery (PA) pressure and heart rate in New York Heart Association (NYHA) Class III heart failure patients who have been hospitalized for heart failure in the previous year. The hemodynamic data are used by physicians for heart failure management and with the goal of reducing heart failure hospitalizations. 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 CardioMEMS device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has been hospitalized in the past year, but it was not for heart failure exacerbation. The record does not indicate any other hospital admission within the past year The coverage criteria of being medically necessary 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 CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS device (wireless pulmonary artery pressure sensor).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance transportation.
You asked the Plan to pre-approve the requested services. You say that you need to be transported to your
doctor's office. The Plan denied your request. The Plan says ambulance services are not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 requested services. Our physician
reviewer found that in this case, the records provided do not indicate that your condition precludes other modes
of transportation, such as stretcher van, or that ambulance service capabilities are required. The record does not
indicate that your clinical condition is such that other methods of transport are contraindicated. 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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve ambulance transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam (92014) provide on
April 9, 2021.
You asked the Plan to waive the copayment for the eye exam. You say that this was a routine vision exam, and
the billed diagnosis of cataracts is irrelevant to this exam. The Plan denied your request. The Plan says this
service was billed as a medical eye exam and the medical records provided indicate this exam was medical in
nature. Therefore, the copayment applies.
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 $45
copayment for each office visit to with specialist for vision services.
You have been asked to pay a $45 copayment for the eye exam. The medical records provided for review
indicate that this exam was provided to evaluate your cataract progression and review vision-related quality of
life. 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 medical eye exam (92014) provide on April 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on June 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
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 code 70450
is a column II code to column I code 70496. 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 the services (70450) provided on June 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing (D4342) provided on July 2, 2021.

You asked the Plan to pay for the scaling and root planing. You say that you have had issues finding consistent dental care on your current plan. You say that you finally found a dentist and your claim was denied. You also say that you were not aware that the services would not be covered. The Plan denied your request. The Plan says scaling and root planing are not listed as covered services.

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 scaling and root planing is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the scaling and root planing (D4342) provided on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electromyography (95886) provided July 22, 2021.
You asked the Plan to pay for the electromyography. You say that the services were medically necessary. The
Plan denied your request. The Plan says this service is non-covered when performed 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 service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for electromyography (95886) provided July 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Medicare Part B drugs and basic radiological services rendered on May 25, 2021 and June 14, 2021.

You asked the Plan to waive the coinsurance for these services. You say that the services should be covered in full. The Plan denied your request. The Plan says the coinsurance was 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 a 20% coinsurance for out-of-network Medicare Part B covered drugs and a 50% coinsurance for out-of-network basic radiological services at an outpatient hospital.

Review of the file shows that you received a diagnostic injection on May 25, 2021. You have been asked to pay a 20% coinsurance for these services. These services fall within the out-of-network Medicare Part B covered 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.

The file shows that you received a computed tomography angiography (CTA) scan of the heart on June 14, 2021. You have been asked to pay a 50% coinsurance for these services. These services fall within the out-of-network basic radiological services at an outpatient hospital 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 Medicare Part B drugs and basic radiological services rendered on May 25, 2021 and June 14, 2021.