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

We decided that the Plan does not have to pay for eyeglass frames (V2020), trifocal lenses (V2300) and antireflective
coating (V2750) provided on March 16, 2021.
You asked the Plan to pay for eyeglass frames, trifocal lenses and anti-reflective coating.. You say that you
received a prescription for eyeglasses, and you do not understand how the benefit is exhausted when you have
never used the benefit. The Plan denied your request. The Plan says you exhausted your benefit, and you are
responsible for the remaining balance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan contract says that you have a $300 allowance to use every calendar year towards the
purchase of eyewear.
We looked at the file and the Plan's rules. The records show you exhausted your maximum allowed benefit of
$300 on March 16, 2021. The records show that you purchased eyeglass frames at $209, trifocal lenses at $379
and an anti-reflective coating at $20, for a total cost of $608. You received the total allowed amount from the
Plan of $300, leaving a balance responsibility of $308 ($608 - $300 = $308). Based on this information, we
decided that the Plan's rules for coverage of eyeglass frames, trifocal lenses and anti-reflective coating. have
not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020), trifocal
lenses (V2300) and anti-reflective coating (V2750) provided on March 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the lab services and x-ray you had on November 16, 2020, and the external shock to the heart procedure you had at an outpatient hospital facility on November 20, 2020.
You asked the Plan to waive the copayments for the x-ray, lab service, and external shock to the heart procedure. You say that you shouldn't owe anything as that is why you have this insurance. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that it has waived the cost sharing originally associated with the Coronavirus testing you received on November 16, 2020. The Plan also says that the allowed amounts for the lab services ($14.06) and the x-ray ($81.21) are less than your copayment obligations, so you are responsible for the full allowed amounts for 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 $150 copayment for x-rays, $40 for labs, and $150 for diagnostic procedures at an outpatient hospital. You have been asked to pay a $150 copayment for the x-ray, a $40 copayment for the lab service, and a $150 copayment for the external shock to the heart procedure. You had each of these services at an outpatient hospital facility. 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 the lab services and x-ray you had on November 16, 2020, and the external shock to the heart procedure you had at an outpatient hospital facility on November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with a pain management specialist on May 27, 2021.
You asked the Plan to waive the copayment for the specialist visit. You say that you went to this doctor's office for an injection. Your doctor had to call to get authorization to do the injection, but after an hour of waiting, he advised that he could not do the injection that day. You say that because all you did was wait, you should not have to pay a copayment. 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 $50 copayment for visits to a specialist.
You have been asked to pay a $50 copayment for the specialist visit. This copayment applies regardless of the extent of services you receive from the 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 the visit you had with a pain management specialist on May 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pelvic floor physical therapy (PT) to be provided by the out-of-network (OON) provider.
You asked the Plan to pre-approve the requested OON PT services. You say that you have been seen by several network physical therapy providers, but they do not specialize in treatment of pudendal neuralgia. You feel that this should be allowed at this time. The Plan denied your request. The Plan says the required services are available from network providers.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The provider at issue in this case is not a network provider with the Plan. 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 requested OON PT services. Our reviewer says that the requested OON services are not shown to be medically reasonable and necessary.
Our physician reviewer found the documentation does not support that evaluation and treatment with the out of network PT provider with specialization in pelvic pain is medically reasonable and necessary in this case. The documentation indicates that the patient is able to receive pelvic floor therapy in-network and is having evidence of reduced pain from this therapy. The request for out of network therapy is not medically necessary and exceeds the patient's medical needs. 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 requested OON PT services have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the requested OON PT services. Therefore, we decided that the Plan does not have to pre-approve pelvic floor physical therapy (PT) to be provided by the out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on February 8, 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 the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.
We looked at the file and Medicare rules. The file shows that the claim was not billed with an appropriate diagnosis code. 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 positron emission tomography (PET) scan rendered on February 8, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 21, 2021, through July 26, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient stay was medically necessary. The Plan denied your request. The Plan says that based on the records we have; this might be an observation stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record shows that at the time of the inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 21, 2021, through July 26, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), provided on May 12, 2021.
You asked the Plan to pay for an oral evaluation. You say that you were not aware the provider was out-of-network. The Plan denied your request. The Plan says you obtained services from an out-of-network provider.
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. Specifically, you received your services out-of-network. This means the service is not covered. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), provided on May 12, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on February 24, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says based on the enrollee's hospice status at the time of service, this claim must be reviewed by Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on February 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 14,
2021, through February 18, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary.
The Plan denied your request. The Plan says additional medical records were requested and not provided.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found that the record indicates that the enrollee was admitted to observation status with a
primary diagnosis of shortness of breath and chest pain, rule out myocardial infarction on February 14,
2021. At the time of admission, electrocardiogram and troponin was normal. However, the enrollee had just
bene discharged on February 13, 2021, after declining cardiac catherization. The enrollee also had hypertensive
emergency at time of presentation with creatinine elevated above baseline. The record does not document a
need to change the enrollee to inpatient status. The elements of the coverage rule are not satisfied. The
requested service is not recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided from February 14, 2021, through
February 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure you had at an
outpatient hospital facility on March 4, 2021.

You asked the Plan to waive the copayment for the arthrocentesis procedure. You say that you believe if you
are covered under Medicare that there should be no copayment. 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 $225
copayment for outpatient hospital services.

You have been asked to pay a $225 copayment for the arthrocentesis procedure. The arthrocentesis procedure
falls within the outpatient hospital services benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment
for the arthrocentesis procedure you had at an outpatient hospital facility on March 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that you have no control over your bladder. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement dentures.
You asked the Plan to pre-approve replacement dentures. You say that the service is medically necessary. The Plan denied your request. The Plan says replacement dentures prior to eligibility are not approved.
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 replacement dentures have not been met. Specifically, the record shows you received your current dentures on January 3, 2018. Therefore, we decided that the Plan does not have to pre-approve replacement dentures.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on
April 19, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that you thought this bill would be paid in
full because this was due to complications from the Coronavirus. 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 $90
copayment for emergency room visits.

You have been asked to pay a $90 copayment for the ER visit. There is no provision in your contract for a
waiver of this amount even if the services were needed as a result of the Coronavirus. 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 emergency room (ER) visit you had on April 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee arthroplasty (27447) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the knee arthroplasty. You say that the service is medically necessary. The Plan denied your request. The Plan says there are in-network providers that can perform this service.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the knee arthroplasty (27447) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right knee genicular nerve ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental, investigational, and unproven.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain. The review has determined that the requested genicular nerve radiofrequency ablation of the right knee 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve right knee genicular nerve ablation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2025) and progressive lenses (V2781)
provided on March 12, 2021.
You asked the Plan to pay for deluxe frames and progressive lenses. You say that you called the Plan prior to
your appointment to see if you had coverage for eyeglasses. You also say that you were told you paid 20% or
$200 of the cost. You feel as if you were misinformed and would like the Plan to compensate you for some of
the charges. The Plan denied your request. The Plan says services will only be covered when they are received
from a provider in the specified vision 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 The Plan contract says that you have a $200 benefit toward the
purchase and fitting of eyeglasses and pair of lenses or contact lenses with a network optical provider, once per
calendar year.
We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. The
Plan covers eyewear when they are received from a provider who participates in the Plan's specified vision
network. Based on this information, we decided that the Plan's rules for coverage of deluxe frames and
progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for deluxe
frames (V2025) and progressive lenses (V2781) provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93010) provided April 19, 2021.
You asked the Plan to pay for the electrocardiogram. You say that the services are medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 93010 is not supported in the medical record. Specifically, an emergency room visit (99285) was already paid for this date of service. No medical records were provided to show that CPT 93010 was a separate and distinct service. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (93010) provided April 19, 2021.