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

We decided that the Plan does not have to pay for anesthesia services (99100) provided on May 17, 2021.
You asked the Plan to pay for anesthesia services. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified.
We looked at the file and Medicare rules. Code 99100 has a status indicator of B and is not separately payable. Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided on May 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided May 23, 2021, through May 26, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you had no choice what hospital you were taken to. The Plan denied your request. The Plan says the copayment was 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 $360 copayment per day, days 1 to 5 for inpatient hospital care. You have been asked to pay a total of $1,080 ($360 copayment x 3 days = $1,080) for the inpatient hospital care. The inpatient hospital care falls within the Inpatient hospital 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 copayment for the inpatient hospital admission and services provided May 23, 2021, through May 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says needs can be met at a lower 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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee 
does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled 
professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. 
The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled 
nursing SNF need. The enrollee's functional level does not require skilled therapy services with  the specialized 
skill, knowledge and judgment of a qualified therapist  to safely and effectively provide medically necessary 
and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or 
a combination of these services) on a "daily basis" in a SNF. As a practical matter, the enrollee does not require 
the necessary services on an inpatient basis, in a skilled nursing facility setting. You can continue to be 
managed in the inpatient rehabilitation facility setting until there is a safe discharge plan. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Toric lenses and Femto laser services provided on June 14, 2021.
You asked the Plan to pay for the Toric lenses and Femto Laser services. You say that approval was given for upgraded lenses and use of the Femto Laser for cataract surgery. You say that you need to be reimbursed the cost that was approved multiple times. The Plan denied your request. The Plan says the services are not covered.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. This includes the additional facility or physician's charge that exceeds the facility or physician's charge for insertion of a conventional intraocular lens (IOL).
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the Toric lenses and Femto laser services provided on June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan has paid the correct amount for a limited oral evaluation provided by an out-of-network provider on April 16, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that you were told that this provider accepted your insurance. The Plan denied your request. The Plan says the out-of-network member liability was applied correctly based on your Plan's benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a limited oral evaluation provided by an out-of-network provider, but the amount you owe might be billed for a greater amount than what the Plan pays.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation provided by an out-of-network provider have been correctly applied. If you choose to see an out-of-network dentist, you might be billed for any amount greater than what the plan pays. The total amount you are being asked to pay is $69.00. Therefore, we decided that the Plan does not have to pay for the remaining amount for a limited oral evaluation provided by an out-of-network provider on April 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 14, 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 billed incorrectly.
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 a skilled nursing facility setting and should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for a comprehensive oral evaluation (D0150) provided on July 5, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that you were not satisfied with the care you received previously. You say that you are satisfied with your new provider. The Plan denied your request. The Plan says that you already had a comprehensive oral evaluation on October 7, 2020.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has failed to provide evidence to show that a comprehensive oral evaluation has been previously provided within the last three years. You can find this information on page 4-78 of the Plan's 2021 Evidence of Coverage. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Resound Enya hearing aid provided on May 13, 2021.
You asked the Plan to pay for the Resound Enya hearing aid. You say that you were not informed you have to go to a plan provider to get the benefit. The Plan denied your request. The Plan says these hearing aids are not covered devices and they were not received from the Plan provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for the hearing aids listed in the Evidence of Coverage only when they are received from the Plan's hearing 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 Resound Enya hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the Resound Enya hearing aid provided on May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair.
You asked the Plan to pay for a shower chair. You say that the service should be covered. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walk-in shower on March 11, 2021. 
 
You asked the Plan to pay for the walk-in shower. You say that you were advised the service would be 
covered. The Plan denied your request. The Plan says the service is not a covered service. 
 
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 a walk-in shower on March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 a power wheelchair. Our reviewer says 
that the item is not medically necessary. Our physician reviewer found the documentation is not clear that the 
mobility deficit is unable to be helped by the use of a walker, cane or manual wheelchair or if you can safely 
maneuver the PMD in the home. The criteria for the requested power wheelchair or power operated vehicle 
have not been met. 

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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can 
be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from May 22, 2021, to May 28, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that you went to the hospital for surgery and had to stay longer than intended due to a complication. You feel this was the physician's fault and you should not be responsible for the cost of the additional inpatient days. The Plan denied your request. The Plan says the inpatient stay was appropriate and reasonable, and your copayment was assessed in accordance with your contract.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for each of the first seven days of an inpatient hospital stay.
You have been asked to pay a $1,350 copayment for the six-day inpatient hospital stay ($225 x 6 = $1,350). 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 admission and services provided from May 22, 2021, to May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483, 80307) provided on May 20, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.
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 drug testing (G0483, 80307) provided on May 20, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravascular ultrasound.
You asked the Plan to pre-approve intravascular ultrasound. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 intravascular ultrasound. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documented plan is for endovenous ablations of the incompetent veins and sclerotherapy of the painful varicose veins, but these interventions have not yet been performed and the enrollee's response to them not re-evaluated. Additionally, the enrollee has a history of peripheral artery disease documented in addition to history of diabetes, hypertension, hypercholesterolemia, but there does not appear to be a plan for objective noninvasive studies of arterial perfusion in the evaluation of the enrollee's leg symptoms. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of intravascular ultrasound have not been met. Therefore, we decided that the Plan does not have to pre-approve intravascular ultrasound.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray (D0220) provided on June 23, 2021.
You asked the Plan to pay for the intraoral x-ray (D0220). You say that the Evidence of Coverage states the dental code is a covered service. 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 intraoral x-ray (D0220) provided on June 23, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the bone marrow biopsy you had at an outpatient hospital facility on January 22, 2021.
You asked the Plan to waive the copayment for the bone marrow biopsy. You say that you thought this would be covered in full. The Plan denied your request. The Plan says the claim for this service was initially processed as out-of-network, charging 20% coinsurance. The Plan has since reprocessed the claim and you are only responsible for a copayment of $275.
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 outpatient surgery and services at an outpatient hospital facility. You have been asked to pay a $275 copayment for the bone marrow biopsy. The bone marrow biopsy falls within the outpatient surgery and services at an outpatient hospital facility 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 bone marrow biopsy you had at an outpatient hospital facility on January 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87496, 87498, 87631, 87798, 87486, 
87541, 87581, 87640, U0003, U0005) provided on January 18, 2021. 

You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan 
denied your request. The Plan says this must be billed through the skilled nursing facility. 
 
The Plan must follow Medicare rules. Medicare rules say that a skilled nursing facility (SNF) must submit all 
Medicare claims for all the services that its residents receive under Part A, except for certain excluded services. 
 
We looked at the file and Medicare rules. The records show that the enrollee was an SNF resident at the time of 
service, meaning this must be billed through the SNF. Based on this information, we decided that Medicare 
rules for coverage of laboratory services have not been met. Based on this information, we decided that 
Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory services (87496, 87498, 87631, 87798, 87486, 87541, 87581, 87640, U0003, 
U0005) provided on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT) to be
provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve IMRT to be provided by an OON provider. You say that the services are
necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide
these services. Therefore, coverage criteria have not been met.
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
intensity modulated radiation therapy (IMRT) to be provided by an out-of-network (OON) provider.