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

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on September
19, 2021.
You asked the Plan to waive the copayment for the urgent care visit. You say that your PCP advised you to go
to urgent care and you should not be responsible for the copayment. 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 $25
copayment for urgently needed services received from providers other than your PCP.
You have been asked to pay a $25 copayment for the urgent care visit. The urgent care visit falls within the
Urgently Needed 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 an urgent
care visit provided on September 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you are at a custodial level of care.

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 continued services. Our physician reviewer found that you do not have documented skilled nursing or therapy needs. You appear to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
September 8, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be
responsible for the copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $45
copayment for each covered visit or consultation in an outpatient location with a specialist.
You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows
services were rendered. 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 specialist office visit
provided on September 8, 2021.
Your complaint about an unsatisfactory visit 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lens exam and fitting (92310) provided on October 6, 2021.

You asked the Plan to pay for the contact lens exam and fitting. You say that you do not understand why the Plan offers a $200 allowance for contact lenses/eyeglasses but does not cover the cost of fitting for these services. The Plan denied your request. The Plan says this service is not covered by your vision benefit. In addition, you were alerted that this service would not be covered when you scheduled the appointment.

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. 

Though the Plan offers a vision 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 contact lens exam and fitting (92310) provided on October 6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that your home is unsafe, and your husband cannot
care for you. The Plan denied your request. The Plan says that there are no noted daily skilled complex nursing
or therapy needs which would meet the guidelines for continued SNF services.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT
code 70450) provided to the enrollee on April 8, 2021.
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your
request. The Plan says the service is not covered as billed.
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 [insert
code at issue] is a column II code to column I code [insert column I code]. 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 CT scan, head or brain; without
contrast material (CPT code 70450) provided to the enrollee on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D1330), periodontal scaling
and root planing (D4341), and palliative (emergency) treatment of dental pain (D9110) provided from June 14,
2019, to September 6, 2019.
You asked the Plan to pay for the oral hygiene instructions, scaling and planing, and emergency treatment of
dental pain. The Plan denied your request. The Plan says these codes are not covered under your benefit
package.
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 oral
hygiene instructions (D1330), periodontal scaling and root planing (D4341), and palliative (emergency)
treatment of dental pain (D9110) provided from June 14, 2019, to September 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic test (CPT code 81479) provided
to the enrollee on August 11, 2021.
You asked the Plan to pay for the service. You say that this should be covered based on this service being
covered by Medicare. The Plan denied your request. The Plan says GeneSight Psychotropic has not been
shown to be useful, is not considered medically necessary and appropriate, is not covered by Medicare and
cannot be approved.
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 pay for the service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found documentation submitted was reviewed and does not meet criteria. No guidelines were found to
support this procedure is not covered by Medicare. However, per Medicare "Genesight testing may only be
ordered by licensed psychiatrists contemplating an alteration in neuropsychiatric medication for patients
diagnosed with major depressive disorder (MDD) (in accordance with DSM lV/V criteria) who are suffering
with refractory moderate to severe depression (as defined by the 17-item Hamilton Rating Scale for Depression
(HAM-D17) score of 14 or greater) after at least one prior neuropsychiatric medication failure. This publication
was from January 23, 2015. No updated publications or guidelines were found. Genesight order medical
necessity documentation documents F33.1 MDD moderate, failed medications, and treatment plan, however
this document is signed by Theodore Ruza with no credentials to support a licensed-psychiatrist.
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 service have not been met. Therefore, we decided that the Plan does not
have to pay for the GeneSight Psychotropic test (CPT code 81479) provided to the enrollee on August 11,
2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 19, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says only one unit of A0428
was provided.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units
provided for each procedure code.
We find that 9.7 units of code A0428 are not supported in the medical record. The medical record only supports
1 unit of code A0428. 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 ambulance services provided on September
19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitoring services provided on June 24, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in
the facility payment.
Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for
services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the
beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to
this service would have been included under the facility claim. Therefore, we decided that the Plan does not
have to pay for the monitoring services provided on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home INR testing kit to be provided by an out-of-
network (OON) provider.
You asked the Plan to pre-approve the OON home INR testing kit. You say that it is medically necessary for
the enrollee to continue with home INR testing. The Plan denied your request. The Plan says they have a
network provider who can supply and deliver the home INR testing kit.
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 home INR testing kit 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 coinsurance for radiation therapy services (G6012, 77280)
provided on August 25, 2021, and August 26, 2021.
You asked the Plan to waive the coinsurance for the radiation therapy services. You say that the services should
be covered as you informed the office you could not afford to pay, and the provider stated they would waive
the costs. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services
provided.
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 Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a 20% coinsurance for radiation therapy services (the total allowed amount is
$820.51 x 20% = 164.10). Radiation therapy services fall 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 coinsurance for radiation
therapy services (G6012, 77280) provided on August 25, 2021, and August 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the
enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent
basis on an outpatient basis, in a long-term care facility, or in the home with home health care services.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on September 14, 2021.
You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says eyewear must be
obtained from a provider in the Plan's vision vendor network.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services when obtained from a provider in the Plan's vision vendor network.
We looked at the file and the Plan's rules. The file shows that the eyeglasses were not obtained from a provider
in the Plan's vision vendor network. Based on this information, we decided that the Plan's rules for coverage of
eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided
on September 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the amputation (27950) provided on July 30, 2021.
You asked the Plan to pay for the amputation (27950). You say that this was not a post operative visit, and the
claim should be reprocessed for proper payment. The Plan denied your request. The Plan says CPT 27590 was
not billed with an appropriate modifier indicating that the service was unrelated to the previous procedure.
The Plan must follow Medicare rules. The rules say that the Medicare approved amount for these procedures
includes payment for the following services related to the surgery when furnished by the physician who
performs the surgery.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the amputation (27950) have not been met. Specifically, an appropriate modifier was not billed
with CPT code 27950 to indicate this was unrelated to the previous procedure. Therefore, we decided that the
Plan does not have to pay for the amputation (27950) provided on July 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip orthosis (L1686 and L2624).
You asked the Plan to pay for the hip orthosis]. You say that the items are medically necessary. The Plan
denied your request. The Plan says the documentation submitted did not sufficiently support the bulled supply
code or indicate the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain relevant medical records which support medical necessity for the supplies provided
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation
without success. Therefore, we decided that the Plan does not have to pay for the hip orthosis (L1686 and
L2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultra-lightweight wheelchair for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this wheelchair is not required full-time.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation is conflicting on the enrollee's mobility deficit and whether it significantly impairs MRADLs in the home. It is not clear if the wheelchair will improve MRADL participation in the home in a significant way. The enrollee states that she would benefit from the wheelchair in out of the home activities such as shopping, and that she is not a full-time wheelchair user. The enrollee is able to use a walker. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultra-lightweight wheelchair for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a tendon sheath (trigger finger) injection
provided on April 29, 2021.
You asked the Plan to waive the copayment for the injection. You say that the procedure took place in the
provider's consultation room with no special equipment. 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 $100
copayment for surgery or other services at an outpatient hospital facility or ambulatory surgical center.
You have been asked to pay a $100 copayment for the injection. The injection falls within the Outpatient
Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical
Centers 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 tendon sheath (trigger
finger) injection provided on April 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (37232) provided on May 4, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot
be verified.
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 37232 is "Revascularization, endovascular, open or
percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List
separately in addition to code for primary procedure)".
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 37232 is
not supported by the records provided. Our reviewer found that the operative report does not include
documentation to support a revascularization, endovascular tibial/peroneal artery with transluminal
angioplasty. To cite the operative report, "A Regalia wire and a micro catheter were used to navigate down the
posterior tibial artery. This met stalling at the total occlusion of its distal vessel. I was unable to navigate
beyond this in the true lumen." The operative report describes that this procedure was unable to be completed,
and therefore cannot be verified.
We looked at this coder's review, the file, and Medicare rules. 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 (37232) provided on May 4, 2021.