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

We decided that the Plan does not have to pay for the eyeglasses (V2020, V2750, V2781) purchased on April
29, 2021.
You asked the Plan to pay for the eyeglasses. You say that you were not told that your Plan would not cover
these glasses. The Plan denied your request. The Plan says you previously received eyewear in February 2020,
which was paid for by the Plan. Eyewear may only be covered once every two years.
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 pair of eyeglasses (lenses and frames) every two years.
We looked at the file and the Plan's rules. Documentation shows that you previously purchased a pair of
eyewear in February 2020, which is less than two years before the date in question. 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, V2750, V2781) purchased on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for scanning computerized ophthalmic diagnostic imaging provided on April 7, 2021.
You asked the Plan to waive the copayment for the scanning computerized ophthalmic diagnostic imaging. You say that you needed the test to see if your peripheral vision is getting worse. The Plan denied your request. The Plan says the service was found to be less than the Plan's cost share of $65.00. Based on these findings, the member was found responsible for a total copayment in the amount of $40.96.
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 $65 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies. You have been asked to pay less than the $65 copayment for the scanning computerized ophthalmic diagnostic
imaging. The scanning computerized ophthalmic diagnostic imaging falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for scanning computerized ophthalmic diagnostic imaging provided on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental x-ray provided on April 19, 2021.
You asked the Plan to pay for the x-ray. You say that you were not told they would be doing a radiographic image. The Plan denied your request. The Plan says the service is not covered.
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 file shows that you received a panoramic radiographic x-ray. Although the Plan offers a dental benefit in excess of Medicare coverage, this type of x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental x-ray provided on April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on March 22, 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.
The Plan must follow Medicare rules. The rules say that both Initial Hospital Care and Subsequent Hospital Care codes are "per diem" services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice. We looked at the file and Medicare rules. The file shows that procedure code 99232 (subsequent hospital care) was previously paid by the Plan from a physician within the same group practice for the billed date of service. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections and electrical stimulation provided to the enrollee on January 26, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says these services are not covered by Medicare when provided 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 injections and electrical stimulation provided to the enrollee on January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the stair lift provided on November 6, 2020.  
You asked the Plan to pay for the stair lift. You say that you could not climb the stairs to your bedroom. The 
Plan denied your request. The Plan says the claim denied correctly.  
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the stair lift provided on November 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on May 4, 2021.
You asked the Plan to pay for the resin-based composite. You say that your coverage includes 2 cleanings plus additional coverage up to at least $500 or $1,000 per year for everything else. You say that this procedure was not an option and the claim should be double checked. 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 resin-based composite provided on May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the general health panel rendered on April 1, 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. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
rendered on April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis device.
You asked the Plan to pre-approve the MyoPro Motion G orthosis device. You say that this request is medically necessary. The Plan denied your request. The Plan says the requested device is considered experimental/investigational at this 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 MyoPro Motion G orthosis device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found At this time the requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and botox for spasticity if needed. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients.
The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. 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 MyoPro Motion G orthosis device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 6 implants (D6010) and 6 extractions (D7140) provided on May 3, 2021.
You asked the Plan to pay for the dental services. You say that you were told that Medicare would reduce the amount of 20% of dental implants and extractions. You say that you chose this dentist due to his expertise of extractions and tooth implants. You also say that you would appreciate any financial assistance because you are on a limited income. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services performed out of network are not covered.
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, 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 implants (D6010) and 6 extractions (D7140) provided on May 3, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the emergency room services provided on April
29, 2021.
You asked the Plan to waive the copay for the services provided. You say that they did not do any form of
treatment. The Plan denied your request. The Plan says the claim processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90
copay for emergency care.
You have been asked to pay a $90 copay for the services provided. The services fall within the emergency care
benefit category. The copay is not determined by the quality of care or the outcome of services. 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 copay for the emergency room services provided on April 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating 
hospital facility on May 20, 2021. 
 
You asked the Plan to waive the copayment for an x-ray. You say that if the doctor wants you to get an x-ray as 
part of your treatment, you should not have to pay for this. The Plan denied your request. The Plan says the 
correct copayment has been applied. 
 
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 $50 
copayment for outpatient diagnostic tests/x-rays/outpatient hospital setting.  
 
You have been asked to pay a $50 copayment for an x-ray. An x-ray was provided; therefore, the correct 
copayment has been applied. An x-ray falls within the outpatient diagnostic tests/x-rays/outpatient hospital setting 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 x-ray provided by a 
participating hospital facility on May 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (0275T).
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this is only supported when you are part of an approved clinical trial.
The Plan must follow Medicare rules. Medicare rules say that percutaneous image-guided lumbar decompression is covered if you are enrolled in an approved clinical study. We looked at the file and Medicare rules. The file does not indicate you are enrolled in a clinical study. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (0275T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided
from March 31, 2021, to April 8, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that you did not realize you had this
copayment required and it is a financial burden. The Plan denied your request. The Plan says this copayment
has been 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 $275
copayment for each of the first six days of a Medicare-covered inpatient hospital stay. There is a $0 copayment
for additional days after the sixth day.
You have been asked to pay a $1,650 copayment for the inpatient care. The inpatient admission lasted more
than 6 days, and you were only charged the cost-sharing for each of the first six days of your stay. ($275 x 6
days = $1,650). 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 inpatient hospital services provided
from March 31, 2021, to April 8, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the emergency room services provided on June 
14, 2021. 
 
You asked the Plan to waive the copay for the services provided. You say that it was not your chose to go to 
the emergency room. The Plan denied your request. The Plan says you are responsible for any cost related to 
the services you receive. 
 
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 $90 
copay for emergency care.  
 
You have been asked to pay a $90 copay for the services provided. The services fall within the emergency 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 copay for the emergency room services 
provided on June 14, 2021. Your complaint that the service received was not your choice 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on February 15, 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 procedure code 99285 is not supported.
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 99285 is Level 5 emergency department visit for evaluation and management of patient with problem immediately threatening life, including comprehensive history and physical examination, and medical decision-making of high complexity.
We find that CPT code 99285 is not supported in the medical record. Specifically, the records do not support Level 5 severity of care. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered on February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330), prophylaxis (D1110), six
crowns (D2752 x6), six endodontic therapies (D3310 x6), and mandibular partial denture (D5226) provided
from December 12, 2019, to December 28, 2019 by an OON and OOA provider.
You asked the Plan to pay for the panoramic x-ray, prophylaxis, crowns, endodontic therapies, and mandibular
partial denture. You say that you are requesting reimbursement for these services provided to you while you
were on vacation. The Plan denied your request. The Plan says these services were obtained out of the Plan's
service area, and do not meet the definition of urgent or emergent care.
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 for non-emergent reasons when received by an OON and/or OOA provider. Therefore, we decided that
the Plan does not have to pay for the panoramic x-ray (D0330), prophylaxis (D1110), six crowns (D2752 x6),
six endodontic therapies (D3310 x6), and mandibular partial denture (D5226) provided from December 12,
2019, to December 28, 2019 by an OON and OOA provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a physician office visit provided on February 5, 2021, by an
OON provider.

You asked the Plan to pay for a physician office visit. You say that you would like this claim reprocessed and
paid. You say that these services were medically necessary. The Plan denied your request. The Plan says prior
authorization was not obtained by the member's primary care physician.

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 a physician office visit provided on February 5,
2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99152, 99153) provided on February 19, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid to the physician in the facility setting. In this case, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older". 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 99152 is not supported by the records provided. Our reviewer found that the documentation does not document the presence of an independent trained observer to assist in monitoring the enrollee's level of consciousness. Therefore, all services in the description of CPT 99152 cannot be confirmed as performed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 99152 have not been met. We also find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT code 99153 for services provided in the facility setting. Therefore, we decided that the Plan does not have to pay for the services (99152, 99153) provided on February 19, 2021.