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

We decided that the Plan does not have to pay for a Toric lens received from July 15, 2021, to August 2, 2021.

You asked the Plan to pay for the lens. You say that if the doctor had done the surgery correctly, you wouldn't have had to get a second opinion and get the Toric lens. The Plan denied your request. The Plan says this is not a covered benefit.

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. 

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 a Toric lens received from July 15, 2021, to August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hearing exam provided on April 7, 2021.
You asked the Plan to waive the copayment for the hearing exam. You say that you thought the test was a part of the exam. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for diagnostic hearing exams. You have been asked to pay a $30 copayment for the hearing exam. This is a separate charge from the office visit. The hearing exam falls within the Hearing Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a hearing exam provided on April 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Needle electromyography (95861) provided on March 24, 2021.
You asked the Plan to pay for code 95861. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 95861 is a column II code to column I code 51785. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Needle electromyography (95861) provided on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic test provided to the enrollee on April 13, 2021.
You asked the Plan to pay for the services. You say that this service is covered by Medicare. The Plan denied your request. The Plan says this test has not been shown to be useful, medically necessary, or appropriate.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that the current evidence does not support the use of GeneSight testing. Medicare does not currently consider the denied testing to be reasonable or necessary. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic test provided to the enrollee on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management service (99397) rendered by the out-of-network (OON) provider on
September 1, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management service (99397) rendered by the out-of-network (OON) provider on September 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a myocardial perfusion imaging test provided on August 10, 2021. We also decided that the Plan does not have to waive the coinsurance for aminophylline and regadenoson injections provided on August 10, 2021.

You asked the Plan to waive the copayment for the myocardial perfusion imaging and injections. You say that you had this test before with no copayment. The Plan denied your request. The Plan says the correct copayment and coinsurance 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 $150 copayment for diagnostic radiology services, not including X-rays. 

Your contract with the Plan also clearly says that you must pay a 10% coinsurance for Part B prescription drugs, including injections.

You have been asked to pay $191.77 for the myocardial perfusion imaging and injections. The myocardial perfusion imaging test falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The aminophylline and regadenoson injections fall within the Medicare Part B Prescription Drugs 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 myocardial perfusion imaging test provided on August 10, 2021. We also decided that the Plan does not have to waive the coinsurance for aminophylline and regadenoson injections provided on August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for measurement of corneal curvature and depth of eye (92136) provided on April 13, 2021, in another country.
You asked the Plan to pay for out-of-country vision services. You say that you were stuck out-of-country and have trouble seeing. The Plan denied your request. The Plan says out-of-country care is only covered in urgent or emergent situations. The services at issue in this case were not emergent, nor were they pre-approved.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of out-of-country care have not been met. Specifically, the services provided were not urgent or emergent. Therefore, we decided that the Plan does not have to pay for measurement of corneal curvature and depth of eye (92136) provided on April 13, 2021, in another country.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that these supplies were covered in the past. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on January 6, 2021.
You asked the Plan to pay for the therapeutic exercises. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code for the services rendered.
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA 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 the therapeutic exercises have not been met. Specifically, this claim was billed by a nurse practitioner. The services of a PTA cannot be billed as services incident to a non-physician practitioner.
Additionally, the record does not indicate that the physical therapist was present in the home. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on January 6, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is not considered useful for back pain 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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental. More research is needed to show safety and efficacy. 

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator.

You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says the provider is incorrectly using codes 64555 and L8679 which are applicable to implantable neurostimulators and not applicable to electro-acupuncture devices such as the auricular stimulator.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist. 

We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an implanted nerve stimulator because the device involve needles inserted around the nerves and not electrodes being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this auricular stimulator have not been met. Based on this information, we decided that Medicare rules for coverage of the stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3/4 porcelain crown (D2783) for tooth # 19 provided on July 16, 2021.

You asked the Plan to pay for the dental service. You say that you were not told this service was not covered. You say that it was medically necessary to have the crown placed. You also say that you followed your dentist's medical judgement to retain as much tooth structure as possible. The Plan denied your request. The Plan says crowns on molar teeth are limited to base metal materials. The Plan also says that the 3/4 porcelain crown is not a covered dental service.

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 3/4 porcelain crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 3/4 porcelain crown (D2783) for tooth # 19 provided on July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an otolaryngology office visit provided on September 13, 2021.
You asked the Plan to waive the copayment for the otolaryngology office visit. You say that this should be considered a routine exam. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment for one routine hearing exam per year. The contract also says that there is a separate cost-share of $40 per visit with a specialist.
You have been asked to pay a $40 copayment for the otolaryngology office visit. Otolaryngology office visits fall within the Hearing Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an otolaryngology office visit provided on September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the negative pressure wound therapy pump you rented from October 14, 2020, to December 14, 2020.

You asked the Plan to waive the coinsurance for the negative pressure wound therapy pump. You say that your shoulder became infected after surgery so you needed this device. You said that the Plan should pay for it. The Plan denied your request. The Plan says it did not deny coverage of this device. Rather, you were charged coinsurance for this item 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 20% coinsurance for durable medical equipment. 

You have been asked to pay 20% coinsurance for the negative pressure wound therapy pump. The negative pressure wound therapy pump falls within the durable medical equipment benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the negative pressure wound therapy pump you rented from October 14, 2020, to December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 26, 2021.
You asked the Plan to pay for the limited exam. You say that this service was necessary and should be covered. The Plan denied your request. The Plan says this service is not covered by your dental 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 limited oral evaluation (D0140) provided on August 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on August 12, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that you were told at the visit that you would not 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 $125 copayment for CT scans. You have been asked to pay the allowed amount of $122.96, which is less than the $125 copayment for a CT scan. A CT scan 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 a CT scan provided on August 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and is currently unstable for transfer to the 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 the enrollee was admitted with acute hypoxic respiratory failure due to COVID-19 pneumonia a day after receiving the vaccination. The record indicates that the enrollee continues to be febrile
with leukocytosis and desaturates readily. The record indicates that the enrollee is clinically unstable and requires acute care services. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical spine surgery for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says conservative treatment measures have not been exhausted.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not contain notes from formal physical therapy for neck pain. More conservative measures are needed. There are no red flags for surgery at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical spine surgery for the enrollee.
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 this is medically necessary. The Plan denied your request. The Plan says alternate settings can be requested, such as a skilled nursing facility, outpatient setting, or home health care.
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. 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.