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

 We decided that the Plan does not have to pay for the home infusion therapy rendered on July 8, 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 that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.  We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on July 8, 2021.   Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on November 3, 2020.  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 were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in the inpateint setting and should have been billed with POS code 21. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 3, 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 September 22, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that this was a necessary second opinion on an initial recommendation. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.     Though the Plan offers a dental benefit in excess of Medicare coverage, 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 August 30, 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 September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye exam provided by an out-of-network provider on October 5, 2021.  You asked the Plan to pay for the eye exam. You say that your primary care physician recommended you get an annual eye exam and coverage should be provided. The Plan denied your request. The Plan says there is no coverage for this service out-of-network.  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 the eye exam provided by an out-of-network provider on October 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  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 there are inadequate records available to determine if the requested LTACH services are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. No records from the acute hospital emergency room evaluation where the enrollee is currently being seen are available for review.    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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete maxillary denture (D5110) provided on January 20, 2021.  You asked the Plan to pay for the complete maxillary denture. You say that you thought your insurance would cover the dentures. The Plan denied your request. The Plan says this 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.  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 complete maxillary denture (D5110) provided on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit provided on June 2, 2021.  You asked the Plan to waive the copayment for an office visit. You say that there has never been a copayment for prior visits. The Plan denied your request. The Plan says the provider is a Tier 2 primary care provider, and the proper 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 $25 copayment for In-Network services obtained from a Tier 2 primary care provider.     You have been asked to pay a $25 copayment for an office visit. an office visit falls within Physician/Practitioner Services, Including Doctor's Office Visits 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 office visit provided on June 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home visit for assistance with activities of daily living and personal care (99509 x 21) provided from June 2, 2021, to June 30, 2021.  You asked the Plan to pay for the home visits. You say that the services were medically necessary per your doctor. The Plan denied your request. The Plan says the provider in this case is not a certified Medicare provider. The Plan also says that payment cannot be made to a provider that is not certified with Medicare.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the home visit for assistance with activities of daily living and personal care (99509 x 21) provided from June 2, 2021, to June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for SelectMDx testing (81479) provided on September 3, 2020.
You asked the Plan to pay for SelectMDx testing. You say that this was medically necessary. The Plan denied
your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that SelectMDx is deemed investigational and code
81479 is not considered medically necessary when used for SelectMDx.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of SelectMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for
SelectMDx testing (81479) provided on September 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for fluoroscopic guidance (77002) provided on September 22, 2020.  You asked the Plan to pay for fluoroscopic guidance. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with an appropriate primary procedure. 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 77002 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for fluoroscopic guidance (77002) provided on September 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aid purchased on May 9, 2021.  You asked the Plan to pay for the hearing aid. You say that you are requesting an appeal for the hearing device. The Plan denied your request. The Plan says this provider is not a network provider with our hearing aid vendor.  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. The Plan pays for hearing aids only when they are received from the Plan's hearing aid vendor.   We looked at the case file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Specifically, the hearing aids were not purchased from the Plan's hearing aid vendor. Therefore, we decided that the Plan does not have to pay for the hearing aid purchased on May 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chiropractic services rendered from October 20, 2021, to November 8, 2021.  You asked the Plan to pay for these services. You say that you feel the services should be covered. The Plan denied your request. The Plan says the services are not covered.  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. The file shows that the chiropractor billed codes 99203 (office visit), 72100 (lumbosacral spine x-ray), 97012 (mechanical traction therapy), and 97015 (therapeutic procedures). Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered from October 20, 2021, to November 8, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve intensity modulated radiation therapy (IMRT) services.  You asked the Plan to pre-approve IMRT services. You say that IMRT services are medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says that the requested services are not medically necessary in this case.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 IMRT services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found IMRT is not investigational for esophageal cancer or any other cancer as it is simply a means to deliver radiation. In situations for which IMRT is not widely used, it becomes necessary to demonstrate its benefit in a patient's treatment in order to determine that it would likely to be more beneficial than standard radiotherapy. In this case, the medical documentation definitively shows that, in this particular patient, that IMRT versus 3D radiation results in clinically significant lowering of dose to the normal tissues (specifically heart). This appears to be a clinically significant reduction and would make these services medically 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 IMRT services have been met. Therefore, we decided that the Plan has to pre-approve intensity modulated radiation therapy (IMRT) services.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services rendered by the out-of-network (OON) provider on September 9, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services rendered by the out-of-network (OON) provider on September 9, 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), two osseous surgeries (D4261 x2), intravenous moderate (conscious) sedation/analgesia (D9239 and D9243), and three additional intraoral periapical x-rays (D0230 x3) provided on June 9, 2021, and July 22, 2021 by an out-of-network (OON) provider.    You asked the Plan to pay for the comprehensive periodontal evaluation, osseous surgeries, intravenous moderate (conscious) sedation/analgesia, and additional intraoral periapical x-rays. The Plan denied your request. The Plan says the comprehensive periodontal evaluation, osseous surgeries, and intravenous moderate (conscious) sedation/analgesia are not covered expenses under your dental plan. The Plan says that your benefits for the additional intraoral periapical x-rays have been satisfied and the frequency limitation has been exceeded. The Plan also says that these services were rendered by an OON provider, and you are responsible for the difference between the Maximum Allowable Fee and the amount the provider bills you for the services.  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 comprehensive periodontal evaluation (D0180), osseous surgery (D4261), and intravenous moderate (conscious) sedation/analgesia (D9239 and D9243) are not among those covered under this benefit. The contract says that you are limited to up to 1 x-ray per year. The record shows that you received a first intraoral periapical x-ray (D0220) on June 9, 2021 and your x-rays benefit has been exhausted. You are also responsible for the difference between the billed amount and allowed amount for covered dental services that are received OON. The Plan also says that prior to these services being received there was a pre-authorization for these same services that was denied. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), two osseous surgeries (D4261 x2), intravenous moderate (conscious) sedation/analgesia (D9239 and D9243), and three additional intraoral periapical x-rays (D0230 x3) provided on June 9, 2021, and July 22, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit provided on October 11, 2021.  

You asked the Plan to waive the copayment for an office visit. You say that the office visit was only for a physical and should not have a copayment. The Plan denied your request. The Plan says the proper copayment was 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 $10 copayment for Medicare-covered physician services.     

You have been asked to pay a $10 copayment for an office visit. An office visit falls within the Physician/Practitioner services, including doctor's office visits 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 office visit provided on October 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services (80053, 80061, 83036, 84443, 85025) provided on July 20, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 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 $0 copayment for laboratory services provided at a primary care physician's office, a specialist's office, a stand-along laboratory, and an urgent care center. Additionally, you must pay a $40 copayment for laboratory services provided at an outpatient hospital setting. If your provider bills as part of a hospital system, you may be responsible for the outpatient hospital setting cost share. 

You have been asked to pay a $40 copayment for the laboratory services provided. Although you have stated that the laboratory services were provided by your primary care physician's office, the contract with the Plan states that if your provider bills as part of a hospital system, you may be responsible for the outpatient hospital setting cost share. The provider in this case did bill the claim as part of a hospital system indicating an outpatient hospital place of service. 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 laboratory services (80053, 80061, 83036, 84443, 85025) provided on July 20, 2021.