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

 We decided that the Plan does not have to pay for the deluxe frame (V2025), and progressive lens (V2781), provided on August 2, 2021.  You asked the Plan to pay for the deluxe frame and progressive lens. You say that the services should be covered. The Plan denied your request. The Plan says you received your services out-of-network.  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 covers these services when obtained in-network.  We looked at the file and the Plan's rules. You received the services from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the deluxe frame and progressive lens have not been met. Therefore, we decided that the Plan does not have to pay for the deluxe frame (V2025), and progressive lens (V2781), provided on August 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the routine dental services provided on February 27, 2021, through August 12, 2021.  You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan denied your request. The Plan says the services were provided by a provider outside the Plan's network.  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 routine dental services provided on February 27, 2021, through August 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve the SNF admission. You say that it is felt that SNF admission is the best option. The Plan denied your request. The Plan says daily skilled services are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital due to confusion and issues with her indwelling Foley catheter. She was diagnosed with a urinary tract infection and treated medically. The most recent therapy documentation indicates the member remains non-ambulatory as per baseline and requires assistance with bed mobility. She has declined working with physical therapy intermittently. The member is medically stable and does not have any complex daily wound care, parental medications or required care for a new or malfunctioning feeding tube.  The member does not require skilled nursing and/or skilled therapy services on a daily basis.  She is medically stable and can receive further rehab services at a lower level of care.  Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility.   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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the IV tubing extension set (S1015) and the infection control supplies (S8301) provided on June 28, 2021.  You asked the Plan to pay for codes S1015 and S8301. 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.  We looked at the file and Medicare rules. In this case, CPT codes S1015 and S8301 have a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. Medicare uses other codes for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pay for the IV tubing extension set (S1015) and the infection control supplies (S8301) provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a lower partial denture (D5212).  You asked the Plan to pre-approve a complete upper denture and a lower partial denture. You say that you visited your dentist on August 18, 2021 for a filling. The provider explained that you needed upper and lower dentures and let you leave with no teeth. You also say you are having serious issues eating, you cannot chew, and you need treatment immediately. You recently had a heart attack, and you need to eat a specific diet and you are unable to do so at this time. The Plan denied your request. The Plan says you have exhausted your dental benefits for the year.  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. The EOC confirms that you receive a $500 maximum benefit amount for supplemental dental services per year. The records show that you received dental services on August 6, 2021 for a total amount of $145. The records also show that you received additional dental services on August 18, 2021, for a total amount of $355. You received your $500 maximum dental benefit on this last date of service. Based on this information, we decided that the Plan's rules for coverage of a complete upper denture and a lower partial denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a lower partial denture (D5212).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physician services provided on August 3, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  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 the physician services provided on August 3, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection of non-compounded foam sclerosant with ultrasound compression maneuvers (36465) provided on August 18, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the injection. You say that you would like this claim to be reconsidered. The Plan denied your request. The Plan says this service was not urgent or emergent. The Plan also says that the treating provider is not a participating provider with the Plan, and authorization was not obtained.  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 the injection of non-compounded foam sclerosant with ultrasound compression maneuvers (36465) provided on August 18, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical procedure (14001 and 14001-59) provided on June 25, 2021.  You asked the Plan to pay for codes 14001 and 14001-59. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of codes 14001 and 14001-59.  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 14001 is Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm.   We find that CPT codes 14001 and 14001-59 are not supported in the medical record. Specifically, the operative report does not include a complete description of code 14001. Based on this information, we decided that Medicare rules for coverage of codes 14001 and 14001-59 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical procedure (14001 and 14001-59) provided on June 25, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the sleep study (95800) provided on April 26, 2021.  You asked the Plan to pay for the sleep study. You say that the sleep study provided was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria for the sleep study provided.  The Plan must follow Medicare rules.  The rules say that polysomnogram (PSG) requires a valid diagnosis and must meet coverage criteria.  We asked our coder 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 sleep study. Our reviewer says that the enrollee did not meet criteria for the sleep study provided. Our reviewer found in this case the consult note provided for review was essentially silent on any symptoms of obstructive sleep apnea (OSA). While there was mention of snoring in the assessment section of the consult note, there was no discussion on the snoring. No other mention was made of any of the cardinal symptoms of OSA.  As such it cannot be determined from the information provided that this request would meet Medicare requirements for coverage of sleep testing.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the sleep study have not been met. Therefore, we decided that the Plan does not have to pay for the sleep study (95800) provided on April 26, 2021.
Appeal type: Surgery
Decision: Partially Favorable

 We decided that the Plan has to hold you harmless for procedure code A9270. We decided that the Plan does not have to waive the copayment for the outpatient surgery you had at an outpatient hospital facility on August 16, 2021.   

You asked the Plan to pay for the outpatient surgery and procedure code A9270. You say that you had a pacemaker inserted and you received a notice that it was denied.  You say you were told that you were not approved for one of the sedatives that you were given.  You stated that you are on a fixed income.  The Plan says that you were charged the appropriate cost sharing for the surgery.  The Plan also says that one of the services you received (procedure code A9270) is not covered, so you were charged for that item in full.  

We decided that the Plan has to hold you harmless for items/services billed with procedure code A9270. While we agree that this code is not a code that is covered by Medicare, the fact remains that you received this service from a Plan provider.  There is no evidence that you were told by the Plan or by the hospital prior to receiving this service that it would not be covered.  According to Medicare rules, you cannot be held responsible for paying for an item or service that was provided to you by a Plan provider unless you were notified prior to the service that it would not be covered.  Because the Plan has provided no evidence of that, we find that it is not appropriate for the Plan to hold you responsible for the charges for code A9270. Therefore, we decided that the Plan has to hold you harmless for procedure code A9270.   

We also decided that the Plan does not have to waive the copayment for the outpatient surgery itself. Your Evidence of Coverage explicitly states that you pa a $345 copayment for outpatient surgery in an outpatient hospital.  Because you had this procedure in an outpatient hospital facility, the Plan's assessment of a $345 copayment is appropriate.  Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgery you had on August 16, 2021.  

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy (PT) services provided from October 12, 2020, to October 30, 2020 by an out-of-network (OON) provider.  

You asked the Plan to pay for the PT services. You say that the enrollee was ordered to receive outpatient services and the facility by a licensed and qualified physician. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that there are PT providers in the enrollee's network area.  

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 the physical therapy (PT) services provided from October 12, 2020, to October 30, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the portable oxygen equipment (E1392), provided on July 7, 2021.  You asked the Plan to pay for the portable oxygen equipment. You say that the item should be covered. The Plan denied your request. The Plan says the purchase of oxygen equipment is not covered.  The Plan must follow Medicare rules. Medicare rules say that for oxygen and oxygen equipment, contractors pay a monthly fee schedule amount per beneficiary. Unless otherwise noted below, the fee covers equipment, contents and supplies. Payment is not made for purchases of this type of equipment.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the portable oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay for the portable oxygen equipment (E1392), provided on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on March 16, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on March 16, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to reimburse you for the over-the-counter eligible items provided on September 19, 2021.  You asked the Plan to reimburse you for the over-the-counter eligible items. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided any documentation that shows that they provided to you documentation listing the criteria that must be met for you to receive reimbursement for your over-the-counter supplemental benefit. The Plan includes pages 91-93 of the Plan's Evidence of Coverage, also known as your contract with the Plan. These pages do not include the criteria that you have to meet in order to receive reimbursement. The Plan has not shown that you received any kind of notice of what this criterion is as the Plan did not include a complete Evidence of Coverage to verify it is included in the contract. We find that the Plan has not substantiated their reasoning for the denial of payment. Therefore, we decided that the Plan has to reimburse you for the over-the-counter eligible items provided on September 19, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve the SNF admission. You say that it is felt that SNF care is needed at this time. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female who suffered a stroke. She is currently admitted to an acute rehabilitation facility. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs and had routine Foley catheter care. Regarding rehabilitation services, the beneficiary received physical, occupational, and speech therapies. The beneficiary was at a moderate to maximal assist level with functional mobility. The beneficiary required varying assist with daily living activities.  There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, skilled therapy is not required on a daily basis at this time. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the electrocardiogram (93000) provided on June 14, 2021.  

You asked the Plan to waive the copayment for the electrocardiogram. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an electrocardiogram on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.  

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 $10 copayment for Outpatient diagnostic tests.   

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an electrocardiogram on June 14, 2021. You have been asked to pay a $10 copayment for the electrocardiogram. The electrocardiogram 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 electrocardiogram (93000) provided on June 14, 2021.   

Your complaint about not receieving this diagnostic testing on the date of service at issue 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.