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 7, 2020.  

You asked the Plan to pay for the hearing aids. You say that the provider is in-network and you were not aware you had to enroll in a special program to obtain hearing aids. You say that this is the primary insurance group, and the claim should be reconsidered. The Plan denied your request. The Plan says you did not use a Plan provider.  

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. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, the hearing aids were not purchased from the Plan's hearing aid vendor. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on April 7, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physical therapy provided by a participating provider.  You asked the Plan to pre-approve physical therapy. You say that additional physical therapy is necessary to prevent the enrollee being stationary. The Plan denied your request. The Plan says the enrollee does not need a continuation of physical therapy.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and is independent with a home exercise program. There is no documentation of a recent injury or decline in function therefore these services are not medically 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 physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) and the scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral of the retina (92134) rendered by the out-of-network (OON) provider on July 22, 2021.  

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 office visit (99214) and the scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral of the retina (92134) rendered by the out-of-network (OON) provider on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eyeglasses and retinal screening photography provided on July 28, 2021.  

You asked the Plan to pay for the eyeglasses and retinal screening photography. You say that you wouldn't have gotten these if you had known they were only covered every other year. You say that you rely on social security and someone should have informed you. The Plan denied your request. The Plan says the glasses exceed the benefit limit, and the retinal screening photography 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 covers eyeglasses once every 2 years. The retinal screening photography is not a covered service as billed.  

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses and retinal screening photography have not been met. Specifically, the Plan paid for the eyeglasses purchased on July 31, 2020, which exhausted your benefit. The retinal screening photography is not a covered benefit as billed. Therefore, we decided that the Plan does not have to pay for the eyeglasses and retinal screening photography provided on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 We decided that the Plan has to pay for a crown and an intraoral first radiographic image. We decided that the Plan does not have to pay for a core buildup. A core buildup is not a covered benefit.  

You asked the Plan to pay for a crown, intraoral first radiographic image, and a core buildup. You say that you would like the Plan to pay for this. The Plan says that non-network dentists have not agreed to provide services at contracted fees.  

We decided that the Plan has to pay for a crown and an intraoral first radiographic image.   

The rules say that the member is responsible for 0% for a crown and an intraoral first radiographic image when provided by an out-of-network provider. Therefore, we decided that the Plan has to pay for a crown and an intraoral first radiographic image.   

We also decided that the Plan does not have to pay for a core buildup.  

A core buildup is not a covered dental service. Therefore, we decided that the Plan does not have to pay for a core buildup.  

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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an auricular stimulator.  

You asked the Plan to pre-approve an auricular stimulator. You say that this item should be considered medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this is not a covered item according to Medicare rules.  

The Plan must follow Medicare rules. Medicare rules say that an auricular peripheral nerve stimulator will be denied as non-covered.   

We looked at the file and Medicare rules. This item is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of an auricular stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular stimulator.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ondansetron 8mg tablet 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 that this does not meet coverage under Medicare Part B.
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 services are medically reasonable and necessary. Our physician reviewer found oral Zofran can be
reasonable and necessary for chemotherapy-induced nausea.
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 been met. Therefore, we decided that the Plan has to pre-approve
Ondansetron 8mg tablet for the enrollee.
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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the office or other outpatient visit for the evaluation and management 
of a new patient (99205) provided on April 23, 2021. 
 
You asked the Plan to pay for the visit. You say that this should be approved and paid. The Plan denied your 
request. The Plan says that that you can safely receive the services you need in other settings. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the visit by a contract provider. The file does not show that the Plan provided notice that 
the visit would not be covered. Under Medicare rules, this means the visit is considered approved by the Plan. 
Therefore, we decided that the Plan has to pay for the office or other outpatient visit for the evaluation and 
management of a new patient (99205) provided on April 23, 2021.  
 
Please note, the Plan forwarded this case as an appeal for the denial of admission to an inpatient rehab 
facility (IRF), but the case record clearly reflects that this appeal was for payment of this visit which 
occurred several weeks before the denial for IRF was issued. As such, we are solely addressing the 
payment for the visit. 
 
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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) provided on August 12, 2021.  

You asked the Plan to pay for the oral hygiene instructions. You say that you should not be responsible for any additional payment to this provider because of the inferior service you received. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits.  

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 oral hygiene instructions (D1330) provided on August 12, 2021.   

Your complaint about the poor service you received from this treating provider 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anti-reflective coating and polycarbonate lenses provided on June 26, 2021.  You asked the Plan to pay for the anti-reflective coating and polycarbonate lenses. You say that you were told the blue color lenses aren't covered so you chose pink instead. You say that you thought glasses were covered every two years and they should be covered. The Plan denied your request. The Plan says your vision plan does not cover lens enhancements.  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 only covers single, lined bifocal, lined trifocal, and lenticular lenses.  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the anti-reflective coating and polycarbonate lenses have not been met. Specifically, lens enhancements are not covered. Therefore, we decided that the Plan does not have to pay for the anti-reflective coating and polycarbonate lenses provided on June 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for wound debridement (11043) provided on June 14, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for wound debridement. You say that even though you did not receive an authorization, you did receive the primary care provider (PCP) order with an urgent request to treat this patient. The Plan denied your request. The Plan says after review, it was determined that there is no record of an approved referral being obtained from the member's PCP prior to services being rendered on June 14, 2021.  

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 wound debridement (11043) provided on June 14, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost for the occupational therapy evaluation and wrist hand finger orthosis provided on July 26, 2021.  

You asked the Plan to waive the cost for the occupational therapy evaluation and wrist hand finger orthosis. You say that you did not have any occupational therapy and all they did was put a brace on your hand. You say that you could have bought the same thing much cheaper, and you do not agree with this charge. The Plan denied your request. The Plan says the cost share applied 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 each Medicare-covered physical, occupational or speech language therapy visit and 20% coinsurance for Medicare-covered durable medical equipment and related supplies.  

You have been asked to pay a total of $99.10 for the occupational therapy evaluation and wrist hand finger orthosis.   

Service Allowed Amount Standard Cost Member Liability 
Occupational Therapy Evaluation $107.64 $20 $20 
Wrist Hand Finger Orthosis $395.52 20% $79.10 
TOTAL:   $99.10  

The occupational therapy evaluation falls within the "Outpatient rehabilitation services" benefit category. The wrist hand finger orthosis falls within the "Durable medical equipment (DME) and related supplies" benefit category. The records show the occupational therapy evaluation was provided. 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 cost for the occupational therapy evaluation and wrist hand finger orthosis provided on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for specialist visits provided on May 24, 2021, and June 7, 2021.  You asked the Plan to waive the copayments for specialist visits. You say that you saw your primary care physician and do not agree with the specialist charges. 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 specialist services.  The record shows that you received specialist services on May 24, 2021, and June 7, 2021. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $80.    You have been asked to pay the total copayment amount of $80 for specialist visits. Specialist visits fall within the physician/practitioner services, including doctor's office visits 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 specialist visits provided on May 24, 2021, and June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the first intraoral periapical x-ray (D0220), resin-based composite (D2392), and endodontic therapy (D3320) provided on August 20, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay more for the first intraoral periapical x-ray, resin-based composite, and endodontic therapy. The Plan denied your request. The Plan says the cost share for these services is correct based on your plan benefits.  

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, you are responsible for the difference between the billed amounts and allowed amounts for services received OON. Therefore, we decided that the Plan does not have to pay more for the first intraoral periapical x-ray (D0220), resin-based composite (D2392), and endodontic therapy (D3320) provided on August 20, 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 morphometric analysis services coded 88374 provided on March 15, 2021.  

You asked the Plan to pay for the morphometric analysis 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 payable.  

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.  

We find that 7 units of CPT code 88374 are not supported in the medical record. This code can only be billed with a maximum of 5 units. This means the amount of units billed exceed the Medicare allowed amount. Based on this information, we decided that Medicare rules for coverage of the morphometric analysis services have not been met. Therefore, we decided that the Plan does not have to pay for the morphometric analysis services coded 88374 provided on March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the extraction (D7210) and unspecified preventive service (D1999) provided on March 4, 2021, by the out of network dentist.  You asked the Plan to pay an additional amount for the dental services. You say that your tooth needed to be extracted that day because your nerve was exposed. You say that you were sent to an oral surgeon 20 miles away. You say that you did not know that the dentist you saw was out of network. You also say that you had no time to check out the situation. The Plan denied your request. The Plan says extractions have a 50% coinsurance. The Plan says if you choose to see an out of network dentist, you might be billed for any amount greater than what the plan pays. The Plan also says that the unspecified preventive service 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 and extraction is listed as covered, there is a 50% coinsurance that applies. In addition, out of network providers may bill you for any amount greater than what the plan pays the provider. Unspecified preventive service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay an additional amount for the extraction (D7210) and unspecified preventive service (D1999) provided on March 4, 2021, by the out of network dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hot or cold pack therapy, the electric stimulation therapy, and ultrasound therapy services received from April 23, 2021 to July 5, 2021.  You asked the Plan to pay for the hot or cold pack therapy, the electric stimulation therapy, and ultrasound therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.  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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the hot or cold pack therapy, the electric stimulation therapy, and ultrasound therapy services received from April 23, 2021 to July 5, 2021.