Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on April 1, 2021.

You asked the Plan to pay for the hearing aids. You say that this place was a lot cheaper to purchase the hearing aids. You say that the Plan provider was too expensive and too far. The Plan denied your request. The Plan says hearing aid coverage only includes hearing aids from the Plan's hearing aid vendors.

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 this physician's review, the file, and the Plan's rules. Specifically, the hearing aids were not purchased from a Plan hearing aid vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on April 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiogram (93000) and an office visit with a specialist (99214) rendered on May 24, 2021.

You asked the Plan to waive the copayment for an electrocardiogram and an office visit with a specialist. You say that you feel you should not pay for the copayment because you are on a fixed income and the provider did not ask for the copayment. The Plan denied your request. The Plan says you were charged the correct copayment 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 $15 copayment for Medicare-covered diagnostic procedures and tests (such as echocardiograms). Your contract with the Plan also clearly says that you must pay a $35 copayment for each physician specialist visit for Medicare-covered services. 

You have been asked to pay a $14.34 copayment, which is less than the $15 copayment for an electrocardiogram. Electrocardiograms fall within the Outpatient Diagnostic Tests and Therapeutic Services benefit category. You have also been asked to pay a $35 copayment for an office visit with a specialist. 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 electrocardiogram (93000) and an office visit with a specialist (99214) rendered on May 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states the enrollee's needs can be met a lower level of care. The Plan states the enrollee's care can be given more safely from home health services at home with supervision or in an assisted living facility. The Plan states the enrollee's needs can also be met in long-term care with part-time skilled services.  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 there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit you had at a pain management clinic on December 16, 2019.  You asked the Plan to waive the copayment for the pain management office visit. You say that you were told these services were covered, but now you are receiving bills with copays. The Plan denied your request. The Plan says you were charged this copayment 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 $20 copayment for services in a specialist's office.   You have been asked to pay a $20 copayment for the pain management office visit. The pain management office visit falls within the services in a specialist's office 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 office visit you had at a pain management clinic on December 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial hospital care services coded 99222 provided on April 3, 2021.  You asked the Plan to pay for the initial hospital care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  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 99222 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit.  We find that CPT code 99222 is not supported in the medical record. Specifically, the documentation does not support a comprehensive history, a comprehensive examination, and medical decision making of moderate complexity. There is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the initial hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care services coded 99222 provided on April 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a crown (D0274), and intraoral radiographic images (D0220 and D0230) provided by a participating provider on June 10, 2021.  You asked the Plan to pay for a comprehensive oral evaluation, a crown, and intraoral radiographic images. You say that you believe that the Plan should pay for this. The Plan denied your request. The Plan says they are upholding the denial of D0274, D0220, D0150, and D0230.  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, D0237, D0220, and D0230 are not among those covered under this benefit. Evidence was provided that shows that D0150 was exhausted on January 7, 2019. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a crown (D0274), and intraoral radiographic images (D0220 and D0230) provided by a participating provider on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a replacement of your upper and lower full denture.  You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied your request. The Plan says the records they received from your dentist show that you received a pair of dentures in August of 2021; therefore, a replacement of your upper and lower full denture would not be covered until August of 2026.  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. Review of the files shows that you received a full set of dentures August 2021. Your 2021 EOC states one (1) set of any combination of maxillary and mandibular full/partial dentures every five (5) years. Therefore, we decided that the Plan does not have to pre-approve a replacement of your upper and lower full denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the consultation (D9310) provided on July 15, 2021.  You asked the Plan to pay for the dental service. You say that you were given a list of treatment codes. You say that the code you are being billed for was not listed. You say that you were given the wrong diagnosis. You also say that the bill you received for $235 is not justified. The Plan denied your request. The Plan says consultation is not listed as a covered 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 consultation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation (D9310) provided on July 15, 2021.   Your complaint about being misdiagnosed 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from September 18, 2018 to September 21, 2018.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the DRG was updated.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    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 pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the facility did not cite any clinical justification for the rebuttal findings, only re-submission of previously reviewed medical records. Upon re-review of the medical records, the findings and determination remain unchanged. The original DRG reported by was not correct in this case.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from September 18, 2018 to September 21, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transport provided on July 5, 2021.  You asked the Plan to pay for the transport. You say that you attached the remittance advice statement and a copy of the denied claim. You say that this should be reviewed for payment. The Plan denied your request. The Plan says your flex benefit limit has been met.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $400 annually toward the cost of transportation services, acupuncture, over-the-counter items, health education and nutritional/dietary benefit.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. The Plan paid the full $400 flex benefit prior to receiving this transport, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the transport provided on July 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Methotrexate Sodium (J9260, J9250).  You asked the Plan to pre-approve Methotrexate Sodium. You say that this treatment has a lower risk of complications. The Plan denied your request. The Plan says this is not supported for the enrollee's condition.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Methotrexate Sodium. Our reviewer says that the requested use of Methotrexate Sodium is not supported. Our physician reviewer found the record indicates that the enrollee has a diagnosis of the keratoacanthoma variant of squamous cell carcinoma. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Methotrexate Sodium have not been met. Therefore, we decided that the Plan does not have to pre-approve Methotrexate Sodium (J9260, J9250).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the unlisted special services, procedures or reports (99199) and unlisted home visit services or procedures (99600) provided from April 19, 2021, to May 12, 2021.  You asked the Plan to pay for the unlisted special services, procedures or reports and unlisted home visit services or procedures. You say that you were not aware that you had to use a provider that was affiliated with Medicare. You also say that the services provided were medically necessary. The Plan denied your request. The Plan says these services were rendered by a provider who is not under contract with the health plan and is not certified for Medicare.  The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the unlisted special services, procedures or reports and unlisted home visit services or procedures have not been met. This provider is not part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the unlisted special services, procedures or reports (99199) and unlisted home visit services or procedures (99600) provided from April 19, 2021, to May 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you received on October 12, 2020.  You asked the Plan to waive the copayment for the ambulance services. You say that you have not had to pay this in the past. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this service ($218.23) is less than your copayment obligation, you are responsible for the full allowed 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 $225 copayment per trip for ambulance services.   You have been asked to pay a $225 copayment per trip for the ambulance services. This copayment applies regardless of what you may have paid in the past. 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 ambulance services you received on October 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there appears to be some concern that these devices are not as effective as surgical decompression, and could lead to higher rates of reoperation.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L3-4 and L4-5 is not medically reasonable or 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (99255) provided on April 13, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.  The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes.   We looked at the file and Medicare rules. Code 99255 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 services (99255) provided on April 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for catheter placement (93460-26-59), sedation (99152, 99153), stent placement (92928-LC), an angiography (75898-26-59), and a transluminal coronary angioplasty (92920-RC) provided on April 7, 2021.  You asked the Plan to pay for catheter placement, sedation, stent placement, an angiography, and a transluminal coronary angioplasty. You say that this is supported in the records. The Plan denied your request. The Plan says complete records have not been received.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.   We find looked at the file and Medicare rules. The submitted medical records are missing the second page of the operative report. Without this information, the  billed codes and modifiers cannot be verified. Based on this information, we decided that Medicare rules for coverage of catheter placement, sedation, stent placement, an angiography, and a transluminal coronary angioplasty have not been met. Therefore, we decided that the Plan does not have to pay for catheter placement (93460-26-59), sedation (99152, 99153), stent placement (92928-LC), an angiography (75898-26-59), and a transluminal coronary angioplasty (92920-RC) provided on April 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the non-emergency transportation: wheelchair van (A0130) and non-emergency transportation: per mile - case worker or social worker (A0160) provided June 1, 2021, and the ambulance service, basic life support, emergency transport (A0429) and ground mileage, per statute mile (A0425) provided June 9, 2021.  You asked the Plan to waive the copayment for the non-emergency transportation and emergency ambulance service. You say that you were in pain and needed transportation. The Plan denied your request. The Plan says the correct copayment was applied to these services.  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 per one-way trip for emergency ambulance services and non-emergency ambulance services.   You have been asked to pay $51.24 for the non-emergency transportation and a $225 copayment for the emergency ambulance service. The non-emergency transportation and emergency ambulance services fall within the Ambulance services benefit category. This means that you have been asked to pay less than or equal to 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 non-emergency transportation: wheelchair van (A0130) and non-emergency transportation: per mile - case worker or social worker (A0160) provided June 1, 2021, and the ambulance service, basic life support, emergency transport (A0429) and ground mileage, per statute mile (A0425) provided June 9, 2021.