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

We decided that the Plan does not have to pay for the eyeglasses (V2020, V2300) and vision exam (Z0100) provided on March 30, 2021, by an out-of-network provider.

You asked the Plan to pay for the eyeglasses and exam. You say that you are enrolled in the additional optional vision benefits and should be reimbursed up to the full $250 allowance for these services. The Plan denied your request. The Plan says supplemental vision benefits are only covered when they are received from a provider in the Plan's specified routine vision network. You used a provider who does not participate in this network. Therefore, the request for reimbursement is denied.

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 specified vision network. 

We looked at the file and the Plan's rules. The provider in this case does not participate in the Plan's routine vision network as specified in the contract. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses and exam have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2300) and vision exam (Z0100) provided on March 30, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head rendered on May 28, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head).
Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head rendered on May 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right leg stab phlebectomy (more than 20 incisions) identified with code 37766.

You asked the Plan to pre-approve right leg stab phlebectomy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that phlebectomy is only covered for certain indications. 

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 right leg stab phlebectomy. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has varicose vein achiness and heaviness in the legs. The enrollee has previously undergoing ablation of the left great and small saphenous veins and phlebectomy. In the right leg, unable to ablate the anterior accessory and small saphenous veins. Both endovenous ablation of the saphenous veins and stab phlebectomy of the tributary veins of the right lower extremity were requested. The endovenous ablation was approved. Due to the reflux in the right saphenous vein not being previously treated, the enrollee does not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of right leg stab phlebectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve right leg stab phlebectomy (more than 20 incisions) identified with code 37766.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmology visit provided on March
4, 2021.
You asked the Plan to waive the copayment for the ophthalmology visit. You say that this was a routine eye
exam, so there should be no copayment. The Plan denied your request. The Plan says this copayment was
charged correctly because although the appointment was made for a routine eye exam, it turned into a medical
exam.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $20 copayment for eye exams to diagnose and treat diseases and conditions of the eye.
The enrollee has been asked to pay a $20 copayment for the ophthalmology visit. The medical records from
this visit show that although the enrollee scheduled a routine eye exam on this date, he was also evaluated and
treated for an abrasion of the left cornea. This is a medical condition and not part of a routine exam.
That is why the ophthalmology visit falls within the eye exams to diagnose and treat diseases and conditions of
the eye benefit category. This means that the enrollee has been asked to pay the correct amount based on the
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in
the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ophthalmology visit
provided on March 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services (CPT code G0151), for the enrollee.
You asked the Plan to pre-approve the physical therapy services. You say that the services are medically necessary. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records show that the enrollee no longer require physical therapy services.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the health plan's denial should be upheld. The enrollee does not have documented skilled therapy needs. The enrollee is functioning at a level commiserate with a lower level of care (i.e. outpatient therapy, HEP). As such, the requested, ongoing, home health physical therapy is not medically necessary or reasonable. 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 physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services (CPT code G0151), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210), first 15 minutes of deep
sedation/general anesthesia (D9222), and consultation (D9310) provided on May 13, 2021 by an OON
provider.

You asked the Plan to pay for the surgical extraction, deep sedation/general anesthesia, and consultation. You
say that these services were necessary to prevent infection. The Plan denied your request. The Plan says these
services were rendered by an OON provider. The Plan also says that you were made aware that the treating
provider was not a Medicare provider and you also signed a treatment 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
covered when they are received OON. The record shows that the office staff confirmed your benefits online,
and advised you verbally and in writing that they do not participate with your plan. Therefore, we decided that
the Plan does not have to pay for the surgical extraction (D7210), first 15 minutes of deep sedation/general
anesthesia (D9222), and consultation (D9310) provided on May 13, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded as 99100 provided on December 7, 2020.
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this claim is not paid separately per Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code 99100 has a status indicator of "B" on the Physician Fee Schedule meaning that payment is bundled with payment made for other services. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded as 99100 provided on December 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the enrollee would be unsafe going home as they have multiple falls in home and also in the shower. You state the enrollee came in with a large burn because they feel in the shower and could not get up for twenty (20) minutes. You state the enrollee needs to go to rehabilitation and the enrollee cannot transfer themself to a chair. The Plan denied your request. The Plan says the stay is not medically necessary.
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 qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is functioning below their baseline. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. The enrollee lives alone and their care needs, as a practical matter, cannot be provided at a lower level of care. 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 SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 21, 2021 by an OON provider.

You asked the Plan to pay for the laboratory services. You say that the doctor is in-network and no referral should be required. You also say that if a referral is required it should already have been done and be part of your medical history. The Plan denied your request. The Plan says the treating provider is not a network provider, the services were not referred by a network provider, or rendered in an in-network facility. The Plan also says that these services were not approved in advance.

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. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 21, 2021 by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the enrollee is not able to return home without
additional help from rehabilitation. You state the enrollee is unable to ambulate without assistance, they live
alone and will be unsafe, and have a risk of falls. The Plan denied your request. The Plan says the stay is not
medically necessary.
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 qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled
therapy needs. The enrollee appears to be functioning below their baseline. The documentation does not yet
show a plateau in function. Daily skilled services are required to establish a maintenance program or to prevent
deterioration of the enrollee's condition.
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 SNF care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray of the ankle you received on June 10, 2021.

You asked the Plan to waive the copayment for the x-ray. You say that you feel as you are being double-charged because you already paid a copayment for the office visit. The Plan denied your request. The Plan says you were charged this copayment correctly because you received a separate x-ray service.

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 x-rays. 

You have been asked to pay a $30 copayment for the x-ray. Plans are permitted to charge separate copayments for x-rays, even if received during an office 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 x-ray of the ankle you received on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).

You asked the Plan to pre-approve the special supplemental benefits for the chronically ill. The Plan denied your request. The Plan says you do not meet the required criteria that makes you eligible for these benefits. The Plan also says that you do not have a high risk of hospitalization or other results adverse for the health, and do not require intensive care coordination.

The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the special supplemental benefits for the chronically ill have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on January 5, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on January 5, 2021.

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on May 17, 2021.

You asked the Plan to pay for the extraction. You say that the tooth had to be pulled and you chose an implant to replace it. You say that implants are not covered but tooth extractions are. The Plan denied your request. The Plan says this is not covered under your medical 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0367)
provided on May 19, 2021.
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you contacted this
provider, told them you were a low-income senior, and only wanted to have done what your dental insurance
plan covers. You also say that you know nothing about the certain types of x-rays, and which x-rays are or are
not approved. The Plan denied your request. The Plan says this procedure is not covered 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 cone
beam CT capture and interpretation (D0367) provided on May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 6 extractions (D7210) and immediate lower denture
(D5140) provided on June 9, 2021.
You asked the Plan to pay for the dental services. You say that you were advised that the enrollee has a PPO
plan with $3,000 available for dental services. You say that the enrollee received a bill for the services that
were performed. You say that you were never advised that the enrollee did not have out of network benefits.
You also say that the enrollee does not have the funds to pay this bill. The Plan denied your request. The Plan
says the provider in this case is out of network. The Plan says that dental services performed out of network are
not covered. The Plan also says that records show that a representative advised that the provider was out of
network and that the plan does not have out of network 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 dental services received out of
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the 6 extractions (D7210) and immediate lower denture (D5140) provided on June 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for physical therapy services provided on April 21, 2021.

You asked the Plan to reduce the copayments for physical therapy services. You state you are concerned that your account will be turned over to collections, and you want the matter resolved. The Plan denied your request. The Plan says you have been charged 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 $40 copayment for per visit of physical therapy services. Your contract also clearly says that if you have more than one type of therapy during the same visit, a cost-sharing will apply to each type.

The records show you received more than one therapy service during your visit. You have been asked to pay a total of $80 in copayments for physical therapy services ($40 physical therapy evaluation + $15.60 for neuromuscular reeducation + $24.40 for self-care training = $80). Physical therapy 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 reduce the copayments for physical therapy services provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection you received on August 20, 2020.

You asked the Plan to waive the coinsurance for the Prolia injection. You say that you believe this was billed incorrectly. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says it has removed the cost sharing associated with the drug administration service, so the only cost sharing applied for this is for the Prolia itself.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B drugs. 

You have been asked to pay 20% coinsurance for the Prolia injection. The Prolia injection falls within the Medicare Part B 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 coinsurance for the Prolia injection you received on August 20, 2020.