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

We decided that the Plan does not have to waive the copayments for arthrocentesis provided from February 22, 2021, and March 22, 2021.

You asked the Plan to waive the copayments for arthrocentesis. You say that you disagree with every aspect of the billing. 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 $300 copayment for outpatient surgery, including services provided at hospital outpatient facilities. 

You received arthrocentesis on February 22, 2021, at an outpatient hospital facility. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $242.59, which is less than the $300 copayment.

You received arthrocentesis on March 22, 2021, at an outpatient hospital facility. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $242.59, which is less than the $300 copayment.

The total amount you owe is: $485.18.

You have been asked to pay the total copayment amount of $485.18 for arthrocentesis. Arthrocentesis 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 copayments for arthrocentesis provided from February 22, 2021, and March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglass frames and lenses (V2020) provided on May 13, 2021.
You asked the Plan to pay an additional amount for eyeglass frames and lenses. You say that you disagree with the denial. The Plan denied your request. The Plan says you exceeded the $100 vision allowance 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 $100 allowance towards the purchase and fitting of eyeglasses and pair of lenses or contact lenses, once per calendar year. The Plan contract also says you are responsible for all costs over the allowance amount. We looked at the file and the Plan's rules. The records show you exhausted your $100 maximum allowed benefit. The records also show you purchased frames at $404.95. The Plan applied your $100 allowance and paid $60 towards the purchase, which brings your total cost share to $243.96 ($404.95 - $100.99 - $60 = $243.96). Based on this information, we decided that the Plan's rules for coverage of eyeglass frames and lenses. have not been met. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglass frames and lenses (V2020) provided on May 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeomin (incobotulinumtoxinA) 200 units/vial #3 (600 units) for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is not approved for use in the lower extremities.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the drug. Our reviewer says that the requested drug is not medically reasoanble or necessary. Our physician reviewer found Xeomin is FDA-approved for the treatment of blepharospasm, cervical dystonia, chronic excessive salivation, rhytide of glabellar skin, and upper limb spasticity. There is not sufficient support to demonstrate that Xeomin is medically reasonable and necessary for the treatment of spastic paraplegia of the lower extremities with spasm.
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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Xeomin (incobotulinumtoxinA) 200 units/vial #3 (600 units) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided
from February 5, 2021, to March 25, 2021.

You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you cannot
afford the charges and were told that you would not owe a copayment for the services. 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 $40
copayment for outpatient rehabilitation services.

You received outpatient rehabilitation services from February 5, 2021, to March 25, 2021, for a total of 13
visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40
(copayment) x 13 (outpatient rehabilitation services) = $520.

You have been asked to pay the total copayment amount of $520 for outpatient rehabilitation services.
Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayments for outpatient rehabilitation services provided from February 5, 2021,
to March 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility or home with caregiver support and home health services.
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for non-surgical management of a tib-fib fracture and has been discharged home with home health services.
Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5261) purchased on April 15, 2021.

You asked the Plan to pay for hearing aids. You say that the hearing aids with the Plan provider were overpriced and did not provide a good enough hearing aid for you. The Plan denied your request. The Plan says hearing aids must be purchased from a provider who is in-network.

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 provided by a Plan's hearing aid provider.

We looked at the file, and the Plan's rules. The records show that the hearing aids were provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5261) purchased on April 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on March 8, 2021.
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. 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. We have also determined that these services are not urgent or emergent, nor were they approved in advance.
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 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 outpatient hospital services provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and
first intraoral periapical x-ray (D0220) provided on March 19, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray.
You say that you and the enrollee contacted the Plan multiple times prior to these services being rendered and
were advised that the provider was in-network. You also say that you would like this claim to be processed for
payment. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. The record shows that the provider called to verify provider eligibility
and plan benefits on March 3, 2021. The provider was given misinformation about their par status. Also,
according to the appeal letter, the provider only inquired about dental codes D2331, D4381, and D9944, but
these codes were not billed by the provider. Therefore, we decided that the Plan does not have to pay for the
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on
March 19, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the biopsy provided on March 29, 2020.

You asked the Plan to reimburse you for biopsy, muscle; superficial (20200). You say that the provider's office told you the medical portion would be covered by your insurance. The Plan denied your request. The Plan says the charge cannot be paid because the provider is on the Medicare opt-out list.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the biopsy provided on March 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 11, 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 11, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound represented by code 76705-26 provided on May 3, 2021.
You asked the Plan to pay for code 76705-26. 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
76705-26 has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as
a separate line item. 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 ultrasound represented by code 76705-26 provided on May 3,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for spherocylinder trifocal lenses (V2303) provided on June 1, 2021.

You asked the Plan to pay for trifocal lenses. You say that you did not get new frames. You also say you used your older frames and had new lenses replaced due to worsening of your eyes. The Plan denied your request. The Plan says you exhausted your benefit, and you are responsible for the remaining balance.

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 $150 allowance once every calendar year for you to use toward the purchase price of eyewear to correct vision. The allowance can only be used for eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames when a provider puts two lenses (at least one of which must have refractive value) into the frame and contact lenses, fitting and dispensing. 

We looked at the file and the Plan's rules. The records show you exhausted your $150 maximum allowed benefit on June 1, 2021. The records also show that you purchased the trifocal lenses at an allowed amount of $359. The Plan applied your $150 allowance which left you with a balance of $209 ($359 - 150 = $209). Based on this information, we decided that the Plan's rules for coverage of trifocal lenses have not been met. Therefore, we decided that the Plan does not have to pay for spherocylinder trifocal lenses (V2303) provided on June 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Positron Emission Tomography (PET) scan provided on
April 8, 2021.

You asked the Plan to pay for the PET scan. You say that the procedure was performed at the request of the
referring doctor. The Plan denied your request. The Plan says the claim denied correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 78815 is Positron emission tomography (PET) with
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization
imaging; skull base to mid-thigh.

We looked at the file and the rules. We find that CPT code 78815 was billed with diagnosis code C55. The
billed diagnosis code is not among those covered for the PET scan at issue. Based on this information, we
decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the
Plan does not have to pay for the Positron Emission Tomography (PET) scan provided on April 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan represented by code 70450 provided on May 3, 2021.

You asked the Plan to pay for code 70450. 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 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 computed tomography (CT) scan represented by code 70450 provided on May 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided from April 27, 2021, to May 6, 2021.

You asked the Plan to waive the copayment for the inpatient hospital admission. You say that you should not pay anything regard to a hospital stay or any hospital bill. 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 $295 copayment for each day for days 1 to 6 for Medicare-covered hospital care.

You have been asked to pay a $295 copayment for each day, for days 1 to 6 of your inpatient hospital admission. ($295 x 6 = $1,770). The inpatient hospital admission 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 provided from April 27, 2021, to May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to further pay for the chiropractic manipulative treatment (98941), mechanical traction therapy (97012), and functional outcomes assessment (G8942) provided June 17, 2021.

You asked the Plan to further pay for the chiropractic manipulative treatment mechanical traction therapy, and functional outcomes assessment. You say that you would like this claim to be reprocessed and approved for further payment. The Plan denied your request. The Plan says the claim has processed correctly, and no additional payment will be made.

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 rules also 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 $20 copayment for Medicare-covered chiropractic services. 

You have been asked to pay a $20 copayment for the chiropractic manipulative treatment. This service falls within the Medicare-covered chiropractic 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. The cost share has processed correctly in this case and no further payment will be made. 

Regarding the mechanical traction therapy and functional outcomes assessment, the records shows that these services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to further pay for the chiropractic manipulative treatment (98941), mechanical traction therapy (97012), and functional outcomes assessment (G8942) provided June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), bitewings - four radiographic images (D0274), prophylaxis - adult (D1110) provided May 25, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the periodic oral exam, bitewing x-rays and dental cleaning. You say that you have been going to this dentist for years and the services have always been covered. The Plan denied your request. The Plan says the services were provided OON and therefore are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the periodic oral exam, bitewing x-rays and dental cleaning when the services are rendered by a network provider. 

We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could provide the items/services at issue in this appeal. We found no exception that would require the Plan to pay for the requested services. Based on this information, we decided that the Plan's rules for coverage of the periodic oral exam, bitewing x-rays and dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), bitewings - four radiographic images (D0274), prophylaxis - adult (D1110) provided May 25, 2021, by an out-of-network (OON) provider.

Your complaint about the Plan potentially covering services rendered by this provider in the past is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.