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

 We decided that the Plan has to pay for a refraction (92015) provided on February 18, 2021.  You asked the Plan to pay for a refraction. You say that you needed this following cataract surgery. The Plan denied your request. The Plan says that this is 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 one routine eye exam per year, up to $70.  We looked at the file and the Plan's rules. The Plan has not indicated that you have received an eye exam in the calendar year prior to the refraction at issue, and the amount charged on this claim line is less than $70.  Based on this information, we decided that the Plan's rules for coverage of a refraction have been met. Therefore, we decided that the Plan has to pay for a refraction (92015) provided on February 18, 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: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pre-approve an oral splint provided by a participating provider.  You asked the Plan to pre-approve an oral splint. You say that your jaw is swollen, and you can barely eat. The Plan denied your request. The Plan says that an oral splint is not medically necessary.  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. The Plan covers an oral splint when the services are medically necessary and reasonable.  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 oral splint. Our reviewer says that you need this medical item. Our physician reviewer found the documentation provided meets the criteria of medical necessity for coverage of an oral splint.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an oral splint have been met. Therefore, we decided that the Plan has to pre-approve an oral splint provided by a participating provider.   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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for home health agency care provided from March 25, 2021, to May 10, 2021.  You asked the Plan to waive the coinsurance for home health agency care. You say that you would like the claims to be reprocessed. 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 15% coinsurance for home health agency care.   You received home health agency care from May 25, 2021, to May 10, 2021. The total allowed amount is $1,456 and 15% of that is $218.40.  You have been asked to pay the total coinsurance amount of $218.40 for home health agency care. Home health agency care falls within the home health agency 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 coinsurance for home health agency care provided from March 25, 2021, to May 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the enrollee's health is declining, and IRF services are medically necessary. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's medical and therapy needs can be met in a less intensive setting.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the debridement of subcutaneous tissue (11042) rendered from June 3, 2021, to June 17, 2021.  You asked the Plan to waive the copayment for the debridement of subcutaneous tissue. You say that each time you were at the office, the service provided was simply just changing the bandage on your wound. You also say that nothing was removed, the wound was clean, and your wound did not require any services other than checking on the healing process and rebandaging. The Plan denied your request. The Plan says you were 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 $225 copayment for each Medicare-covered outpatient hospital facility visit.   You have been asked to pay a $225 copayment for each of three services of the debridement of subcutaneous tissue, which is a total of $675. The debridement of subcutaneous tissue falls within the Outpatient Surgery benefit category. The records show you received services at an outpatient hospital facility for each debridement service from June 3, 2021, to June 17, 2021. 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 debridement of subcutaneous tissue (11042) rendered from June 3, 2021, to June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the denture repairs provided on June 8, 2021.  You asked the Plan to pay for the denture repairs. You say that denture repairs should be covered. The Plan denied your request. The Plan says the service 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 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 denture repairs provided on June 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dialysis and cinacalcet provided from January 2, 2021, through January 31, 2021.    You asked the Plan to pay for the dialysis and cinacalcet. You say that procedure code 90999 for dialysis with modifier G7 is valid per guidelines and the patient's medical records. You say that the claim was denied in error and should be reprocessed. The Plan denied your request. The Plan says the claim processed correctly.  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 90999 is unlisted dialysis procedure, inpatient or outpatient. The CPT Code Manual definition of code J0604 is cinacalcet, oral, 1 mg, (for esrd on dialysis).  We find that CPT code 90999 and J0604 is not supported in the medical record. Specifically, payment for J0604 is included in the ESRD PPS and separate payment is not made. Billing the AX modifier with CPT code J0604 is no longer appropriate. Based on this information, we decided that Medicare rules for coverage of the dialysis and cinacalcet have not been met. Therefore, we decided that the Plan does not have to pay for the dialysis and cinacalcet provided from January 2, 2021, through January 31, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy (90837) rendered by the OON provider on August 11, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90837) rendered by the out-of-network (OON) provider on  August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for hearing aids provided on January 3, 2021.  You asked the Plan to reimburse you for hearing aids. You say that you have purchased hearing aids from other companies, and they were all too expensive. You say this provider only charged you $2,500.00 for your hearing aid purchase. The Plan denied your request. The Plan says the Plan does not reimburse for hearing aids purchased from providers out-of-network with the Plan's hearing aid provider.  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.   We looked at the file and the Plan's rules. The file shows the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on January 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve computed tomography, abdomen and pelvis (74178) computed tomography, thorax (71250).  You asked the Plan to pre-approve the CT scan. You say that the medical records provided support the necessity of the services in dispute The Plan denied your request. The Plan says no progress, office notes were provided with this request therefore, medical necessity has not been established.  The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee with end stage renal disease who is being seen in the transplant nephrology clinic to be evaluated for a kidney transplant. A CT of the thorax was requested to evaluate a lung nodule that showed no changes between 2017 and 2019. Based on the fact that there were already multiple years of no changes with the lung nodule, there is no sufficient support made for another follow-up CT for this reason. There was no other indication described in the provided notes. Therefore, this request for CT will be considered not medically necessary.  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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography, abdomen and pelvis (74178) computed tomography, thorax (71250).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eyeglasses (V2781, V2784) provided on June 15, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the eyeglasses. You say that you are entitled to the $125 allowance, and the participating provider did not have the glasses you needed so you went to a different provider. The Plan denied your request. The Plan says out-of-network care is only covered by your Plan in certain limited circumstances. These services were not urgent or emergent, nor were they pre-approved. These services could have been received from an in-network provider. Routine vision care services are not covered when obtained from out-of-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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 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 up to $125 per year for routine eyewear when purchased from a participating provider.   We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of routine eyewear have not been met. 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 eyeglasses (V2781, V2784) provided on June 15, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140), therapeutic pulpotomy (D3220), and an intraoral radiographic image (D0220) provided by an out-of-network provider on June 9, 2021.  You asked the Plan to pay for a limited oral evaluation, therapeutic pulpotomy, and an intraoral radiographic image. You say that your dentist told you to not go to the only in-network provider. You say that you had an open tooth and went to an out-of-network provider. The Plan denied your request. The Plan says dental services must be provided by an in-network provider.  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. The Plan covers a limited oral evaluation, therapeutic pulpotomy, and an intraoral radiographic image when the services are provided by an in-network provider.   We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, therapeutic pulpotomy, and an intraoral radiographic image have not been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), therapeutic pulpotomy (D3220), and an intraoral radiographic image (D0220) provided by an out-of-network provider on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), and extraction (D7210) provided on April 28, 2021.  You asked the Plan to pay for the dental services. You say that your bank account is empty due to this claim. You also say that you think you should not pay the full amount. The Plan denied your request. The Plan says the limited oral evaluation is not listed as a covered service. The Plan says that periapical x-ray is not listed as a covered service. The Plan also says the extraction is not listed and therefore is not a covered service either.  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 limited oral evaluation (D0140), periapical x-ray (D0220), and extraction (D7210) provided on April 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that you would like an IRF admission covered. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure (CPAP) machine provided on July 18, 2021.  You asked the Plan to waive the coinsurance for CPAP machine. You say that you had paid approximately 10 of the 13 months of the lease agreement for this item and have paid over the required lease amount with continuing monthly payments required. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct, and you will not acquire ownership of rented durable medical equipment no matter how many cost-share payments you make for the item while you are a member of the Plan.  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 CPAP machine. As a member of the Plan, you never acquire ownership of a CPAP machine no matter how many cost-share payments you make. The allowed amount of this claim is $38.67, resulting in a coinsurance obligation of $7.73.  You have been asked to pay 20% coinsurance for CPAP machine. CPAP machine falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for a continuous positive airway pressure (CPAP) machine provided on July 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewing x-rays (D0274), initial periapical x-ray (D0220), and additional periapical x-ray (D0230) provided on July 26, 2021.  You asked the Plan to pay for the dental services. You say that the dentist advised that she needed to take images. You say that you did not question this. You say that you were not told that the services would not be covered. You also say that if you had known they would not be covered, you would not have gotten them done. The Plan denied your request. The Plan says 1 set of bitewing x-rays are covered per calendar year. The Plan says that 1 periapical x-ray is covered per calendar year. The Plan also says that the frequency limits have been exceeded.  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 and the x-rays are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a set of bitewing x-rays and a periapical x-ray that you received on January 25, 2021. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274), initial periapical x-ray (D0220), and additional periapical x-ray (D0230) provided on July 26, 2021.