Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 25, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. 

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140)
provided on March 15, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you attended to dentist
appointments for a second opinion and were informed you would not have to pay anything out of pocket for
these visits. You also say that you feel this is unfair that you are being held responsible for these bills after
being told they would be taken care of. The Plan denied your request. The Plan says this service exceeds the
maximum count allowed per period.

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, problem focused limited oral
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem
focused limited oral evaluation (D0140) on February 17, 2021 and your problem focused limited oral
evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for
the problem focused limited oral evaluation (D0140) provided on March 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for wheelchair van transport provided on May 11, 2021.

You asked the Plan to pay for wheelchair van transport. The Plan denied your request. The Plan says Medicare does not cover non-emergent transportation provided by wheelchair vans, taxis, stretcher vans or ambulettes.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. 

The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for wheelchair van transport provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse you for single vision sphere lenses (V2100) purchased on March 8,
2021.

You asked the Plan to reimburse you for single vision lenses. You say that you disagree with the denial and you
should be reimbursed as the Plan advised you to see this provider. The Plan denied your request. The Plan says
that if they decide that medical care is covered, they will pay for their share of the cost.

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 contract says that you have a $200 allowance to use towards the purchase of frames and
lenses once per calendar year.

We looked at the file and the Plan's rules. The documentation submitted indicates that you were referred for
these services by the Plan. As such, the Plan is responsible for reimbursing you the full amount for the lenses.
Based on this information, we decided that the Plan's rules for coverage of single vision lenses have been met.
Therefore, we decided that the Plan has to reimburse you for single vision sphere lenses (V2100) purchased on
March 8, 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: Unfavorable

We decided that the Plan does not have to pay for the treatment of a root canal obstruction (D3331) provided
on May 21, 2021.

You asked the Plan to pay for the dental service. You say that you have a limited income. You say that you are
stressed and anxious knowing that you need these services. You say that The Plan denied your request. The
Plan says treatment of a root canal obstruction is not listed as a covered service. The Plan also says that this
service is not covered by Medicare.

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. Additionally, the services you are asking the Plan to pay for involve
the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your
teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the
Plan does not have to pay for the treatment of a root canal obstruction (D3331) provided on May 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for group psychotherapy provided from November 5, 2020, to November 18, 2020.

You asked the Plan to pay for group psychotherapy (90853). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the provider's license does not meet the licensure requirements to bill this psychiatric service.

The Plan follows Medicare rules. The rules say that no Medicare payment may be made for items or services provided directly by a physician or practitioner who is not eligible to enroll in Medicare. 

The provider is not qualified to receive payment under Medicare or the benefit plan. Therefore, we decided that the Plan does not have to pay for group psychotherapy provided by a Mental Health Counselor from November 5, 2020, to November 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on February 26, 2021.

You asked the Plan to waive the copayment for the lab services. You say that you were under the impression that there was no copayment for lab services. You say that these labs were done at your doctor's office. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that there is no copayment for lab services if you get them at a physician's office or an independent lab location. The Plan says that because you received these lab services at a hospital facility, the copayment applies.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for lab services received at any location other than a doctor's office or an independent lab location.

You have been asked to pay a $25 copayment for the lab services. Records show that the facility where you received these services and that billed for these services is considered an outpatient hospital facility. 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 lab services you received on February 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to a LTACH.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee appears to be improving and only requires short-term additional acute care services for stabilization and weaning which can be safely provided at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, request for LTACH will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on March 26, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that you are appealing this claim. 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 $80 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in an in-network physician's office or at an in-network free-standing facility (such as a radiology center or medical clinic). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $80 copayment for the ultrasound.

You have been asked to pay a $58.03 copayment for the ultrasound. The ultrasound 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 the ultrasound provided on March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a bronchoscopy provided on April 1, 2021.

You asked the Plan to waive the copayment for a bronchoscopy. You say that you were never informed at any point that you would owe a copayment. 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 a $150 copayment for outpatient surgery, including services provided at hospital outpatient facilities. 

You have been asked to pay a $150 copayment for a bronchoscopy. A bronchoscopy falls within the outpatient surgery, including 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 bronchoscopy provided on April 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital observation and self-administered drugs provided from March 1, 2021, to March 4, 2021.

You asked the Plan to pay for hospital observation and self-administered drugs. You say that you cannot afford these charges. The Plan denied your request. The Plan says this 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 $295 copayment for outpatient hospital observation. The rules also say that Medicare Part B generally does not pay for self-administered drugs. 

You have been asked to pay a $295 copayment for hospital observation. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The self-administered drugs provided are not covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for hospital observation and self-administered drugs provided from March 1, 2021, to March 4, 2021.

Benefits for self-administered drugs 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 reimburse you for polycarbonate lenses (V2784) provided on March
29, 2021.

You asked the Plan to reimburse you for polycarbonate lenses. You say that according to your Plan brochure,
you have a $250 allowance for the cost of eyewear, and you assumed you would get reimbursed the allowance
amount. The Plan denied your request. The Plan says this service is not a covered benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan contract says that you have a $250 allowance for routine eyewear including the lenses and
one pair of eyeglass frames or contact lenses every 2 years. The Plan contract also says that eyewear does not
include lens options such as tints, progressives, transition lenses, polish and insurance.

We looked at the file and the Plan's rules. The records show that you purchased eyeglass frames and the Plan
covered the allowed amount. The records also show that you purchased polycarbonate lenses which are not
covered benefits of Medicare or the Plan. Based on this information, we decided that the Plan's rules for
coverage of polycarbonate lenses have not been met. Therefore, we decided that the Plan does not have to
reimburse you for polycarbonate lenses (V2784) provided on March 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870).
You asked the Plan to pre-approve the surgery. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

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 records do not support the need for daily therapy on an inpatient basis.

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 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 skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a health club membership (S9970) for the 2020
benefit allowance.
You asked the Plan to reimburse you for a health club membership. You say that you mailed in the
reimbursement form on time and due to the pandemic, it arrived late. You also say, it is not your faulty and you
should be reimbursed. The Plan denied your request. The Plan says reimbursement requests must be received
by the Plan no later than March 31st of the following year.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that the
Plan reimburses you up to $300 each calendar year towards your cost for membership in a qualified health club
or fitness facility, covered instructional fitness classes, participation in wellness programs, memory fitness
activities, acupuncture, and/or covered nutritional counseling sessions with a licensed nutritional counselor or
registered dietician. You pay all charges over $300 per calendar year. Reimbursement requests must be
received by the Plan no later than March 31st of the following year.
The Plan's rules for coverage of gym benefits have not been met because the reimbursement request was
submitted outside of the coverage year. The records show that initially, the receipt submitted showed proof of
payment of only $80.21. The Plan then received proof of payment for $141.21. Please note, the records indicate
that the Plan made a one-time exception to approve part of your request in the amount of $141.21. Proof of
payment for the remaining balance of the benefit allowance was received after March 31st. Therefore, we
decided that the Plan does not have to reimburse you for a health club membership (S9970) for the 2020 benefit
allowance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466) and humidifier (E0562).
You asked the Plan to pre-approve a portable ventilator and humidifier. You say that the item is medically necessary. The Plan denied your request. The Plan says he requested device is being used in the bilevel PAP mode rather than being used as a home ventilator.
The Plan must follow Medicare rules. The rules say that ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and 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 a portable ventilator and humidifier have not been met. Specifically, this item is not covered for its intended use. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator (E0466) and humidifier (E0562).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided on April 17, 2021.

You asked the Plan to pay for occupational therapy services. You say that the records show the billed code is valid according to the services provided. You say that the medical records should be reviewed, and the claim should be reconsidered for reimbursement. The Plan denied your request. The Plan says the billed service is not supported.

The Plan must follow Medicare rules. Medicare rules say that therapy services billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. Medicare rules also say that the services of an OTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy services have not been met. Specifically, the records do not indicate if the rendering provider was an occupational therapist or an OTA. A nurse practitioner is not able to bill for the services of an OTA because the nurse practitioner is not a therapist. There is no evidence that the nurse practitioner was on the premises to be able to bill for OT services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided on April 17, 2021.