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

We decided that the Plan does not have to waive the copayment for the x-ray provided on April 13, 2021.
You asked the Plan to waive the copayment for the wrist x-ray (73110). You say that you should only have a $40 specialist copayment. The Plan denied your request. The Plan says you were charged the $40 specialist copayment and the $15 x-ray 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 $15 copayment for Outpatient Diagnostic Tests. You have been asked to pay a $15 copayment for the wrist x-ray (73110). The wrist x-ray (73110) falls within the Outpatient Diagnostic Tests 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 x-ray provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on June 16, 2020, to June 17, 2020.
You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $611. The total amount you are being asked to pay is $122.20 ($611 x 20% = $122.20). The correct coinsurance has been applied to the injection that was provided. An injection falls 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 coinsurance for an injection provided by a participating provider on June 16, 2020, to June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on May 18, 2021.
You asked the Plan to pay for an eye refraction. You say that you saw this provider briefly three times due to very poor eyesight from corneal edema and he should not be paid. The Plan denied your request. The Plan says the service at issue is not a covered 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 an eye refraction is only covered by the Plan when it is performed as part of a routine screening. We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, and therefore is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the oral evaluation (D0120) and prophylaxis (D1110) provided on February 2, 2021.
You asked the Plan to pay for the dental services. You say that the day of your appointment was the only day the dentist was available. You say that you thought it had been 6 months since your last appointment. You also say that you are on a lot of medications, and it breaks your teeth. The Plan denied your request. The Plan says that 1 oral evaluation is covered every 6 months. The Plan says that 1 cleaning is covered every 6 months. The Plan also says that the frequency limits have been exceeded for these services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dental services when the services are medically necessary and reasonable.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met. Specifically, the record shows that 6 calendar months have passed since the enrollee last received these services on August 5, 2020. Therefore, we decided that the Plan has to pay for the oral evaluation (D0120) and prophylaxis (D1110) provided on February 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a
lower level of 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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You have a past medical history of admission for
COVID pneumonia in November 2020 and for congestive heart failure in May 2021. You are living at home
with ongoing weakness despite home health physical therapy. Your 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
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program. 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.
Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology, in situ hybridization (CPT code 88121) provided to the enrollee on April 1, 2021.
You asked the Plan to pay for the testing. You say that the pathologist note indicates what the examination was in search of and the clinical history/information of the enrollee. The Plan denied your request. The Plan says there is no documentation of a diagnosis for which this testing may be done on the claim form.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, the testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. The services are not authorized because Cytopathology, in situ hybridization (eg, FISH) (CPT code 88121-26) is not a Medicare benefit for the diagnosis listed on the claim Z87.448/Personal history of other diseases of urinary system and is done for screening purposes. Cystoscopy in conjunction with bladder tumor markers is standard practice to evaluate patients with symptoms suggesting bladder cancer and to monitor treated patients for recurrence or progression. Bladder cancer tumor markers performed by any technology immunoassay, molecular or FISH testing, are not covered for screening of all patients with hematuria. Bladder tumor markers are not expected to be performed until other diagnostic studies fail to identify the etiology of the hematuria. Urine cytology is not considered a bladder tumor marker. Therefore, we decided that the Plan does not have to pay for cytopathology, in situ hybridization (CPT code 88121) provided to the enrollee on April 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2025), progressive lenses (V2781) and
polarization per lenses (V2762) provided on April 8, 2021.
You asked the Plan to pay for deluxe frames, progressive lenses and polarization per lenses. You say that you
did not know the provider was not in network with your vision benefits. The Plan denied your request. The
Plan says these services are covered when provided by an in-network provider.
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 receive one routine eye exam and $100 towards the purchase of either
one pair of eyeglasses or contact lenses per calendar year with a network optical provider.
We looked at the file and the Plan's rules. The records show that the services at issue were provided by an out -
of-network provider. These services are not covered by the Plan when provided by an out-of-network provider.
Based on this information, we decided that the Plan's rules for coverage of deluxe frames, progressive lenses
and polarization per lens have not been met. Therefore, we decided that the Plan does not have to pay for
deluxe frames (V2025), progressive lenses (V2781) and polarization per lenses (V2762) provided on April 8,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based fillings (D2392, D2331) and unspecified preventative procedure (D1999) provided on March 22, 2021.
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan denied your request. The Plan says they have paid part of the cost for the covered services provided on March 22, 2021. However, on this date you met and exceeded your annual coverage limit of $500 for supplemental dental care. The remaining cost is your responsibility. In addition, the unspecified preventative procedure is not 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. The Plan covers certain supplemental dental services for up to $500 per year. After the annual maximum is exhausted, any remaining charges are your responsibility. 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 or exceeded the Plan's coverage limit under this benefit. The record shows that the Plan has paid the maximum allowed $500 for dental services for you in 2021. Therefore, we decided that the Plan does not have to pay for the resin-based fillings (D2392, D2331) and unspecified preventative procedure (D1999) provided on March 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation device for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that this is non-covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulators are electro-acupuncture devices which are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic imaging provided on February 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for diagnostic imaging. You say that the member could not be transport. You say that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 diagnostic imaging provided on February 10, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (87633) provided on February 25, 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 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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that use is restricted to when more limited panels would not be medically appropriate. 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 pay for the lab services (87633) provided on February 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on April 14, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 37225 is not supported.
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 37225 is revascularization, endovascular, open or
percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same
vessel, when performed.
We find that CPT code 37225 is not supported in the medical record. Specifically, there is no documentation of
an open or percutaneous endovascular revascularization of a unilateral femoral or popliteal artery(s). Based on
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore,
we decided that the Plan does not have to pay for the surgical services rendered on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vaccine provided on April 22, 2021.
You asked the Plan to pay for Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715) and
immunization administration (90472). You say that during a physical you were offered the vaccine and you
were not aware you would be billed for the shot so you should not have to pay for it. The Plan denied your
request. The Plan says this vaccination and administration are not covered when billed with a non-covered
diagnosis.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, diphtheria
toxoids and acellular pertussis vaccine (Tdap) (90715) and immunization administration (90472). The Plan
follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, diphtheria
toxoids and acellular pertussis vaccine (Tdap) (90715) and immunization administration (90472). Therefore,
we decided that the Plan does not have to pay for the vaccine provided on April 22, 2021.
Benefits for Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715) and immunization
administration (90472) may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a lower partial denture (D5226) provided on December 8, 2020.
You asked the Plan to pay for a lower partial denture. You say that the service was in 2021 and should process with the allowance for that year. The Plan denied your request. The Plan says the benefit maximum had already been met; therefore, the Plan will not cover this amount.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a lower partial denture have not been met. Specifically, the record shows that you had exhausted your dental benefit maximum. Therefore, we decided that the Plan does not have to pay for a lower partial denture (D5226) provided on December 8, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on April 28, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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 services (70450) provided on April 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of 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.
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a fall, urinary tract infection, anemia, and hydronephrosis. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
You asked the Plan to pre-approve a complete upper denture. You say that your dentures are broken, and you would like to get new ones. The Plan denied your request. The Plan says you have exceeded the quantity allowable under you plan for this 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. The Plan covers a complete or partial denture every five years. We looked at the file and Medicare rules. The Plan provided documentation showing that an upper denture was previously covered on August 12, 2019. Based on this information, we decided that the Plan's frequency limit for coverage of an upper denture has been exceeded. Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on June 22, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on June 22, 2020.