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

 We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), complete series x-ray (D0210) provided on February 17, 2021, the comprehensive oral evaluation (D0150), diagnostic cases (D0470), and prophylaxis (D1110) provided on April 27, 2021, clinical crown lengthening (D4249) provided on May 25, 2021, and the crown (D2740), root canal (D3310), and prefabricated post and core in addition to a crown (D2954) provided on June 8, 2021.  You asked the Plan to reimburse you for the dental services. You say that you paid for the services out of pocket on each date of service for February 17, 2021, March 29, 2021, May 25, 2021, June 8, 2021, June 29, 2021, and July 27, 2021. You say that you have not received reimbursement for the services you received. You also say that you were never told that the provider was out of network. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services received out of network are not covered.  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, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), complete series x-ray (D0210) provided on February 17, 2021, the comprehensive oral evaluation (D0150), diagnostic cases (D0470), and prophylaxis (D1110) provided on April 27, 2021, clinical crown lengthening (D4249) provided on May 25, 2021, and the crown (D2740), root canal (D3310), and prefabricated post and core in addition to a crown (D2954) provided on June 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the treatment team clearly states that skilled therapy and skilled nursing are not needed.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible and coinsurance for outpatient therapies provided by an out-of-network provider on March 24, 2021, to July 28, 2021.  You asked the Plan to waive the deductible and coinsurance for outpatient therapies. You say that you do not agree with these services being processed as out-of-network. The Plan denied your request. The Plan says the correct cost sharing charges have 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 $500 deductible and a 50% coinsurance for outpatient rehabilitation services/out-of-network.    You have been asked to pay a total amount of $331.44 for outpatient therapies.   Date of Service Allowed Amount Deductible Coinsurance Total Amount March 24, 2021 $161.38 $161.38 --- $161.38 March 29, 2021 $56.69 $56.69 --- $56.69 April 5, 2021 $56.69 $56.69 --- $56.69 March 24, 2021 $56.69 --- 50% $28.34 July 28, 2021 $56.69 --- 50% $28.34  Total Amount Being Asked to Pay: $161.38 + $56.69 + $56.69 + $28.34 + $28.34 = $331.44  Outpatient therapies falls within the outpatient rehabilitation services/out-of-network 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 deductible and coinsurance for outpatient therapies provided by an out-of-network provider on March 24, 2021, to July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve oxygen and supplies to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the 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 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 oxygen and supplies to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for eyeglasses provided on May 6, 2021.  You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says you received eyewear on May 11, 2020, and payment was issued to the provider for the vision items. Your Plan specifies that you are limited to 1 pair of lenses and frames every 2 years.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every 2 years.  We looked at the file and the Plan's rules. The file shows that you have exceeded the maximum eyewear benefit. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on May 6, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to waive the coinsurance for laboratory services (80061, G0103, 80053, 83036) rendered on June 1, 2021.  You asked the Plan to waive the coinsurance for laboratory services. You say that you feel you should not be charged a copayment. The Plan denied your request. The Plan says that you were charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for Medicare-covered laboratory services.   The Plan says you must pay $16.24 for a 20% coinsurance of the allowed amount for laboratory services. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for laboratory services. Therefore, we decided that the Plan has to waive the coinsurance for laboratory services (80061, G0103, 80053, 83036) rendered on June 1, 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 pay for skilled nursing facility (SNF) services provided to the enrollee between May 13, 2020 and May 31, 2020.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there are inconsistencies between the documentation in the medical records and the coding of the 5 day Minimum Data Set (MDS) assessment.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the available clinical documentation does not support coding of parenteral/IV feeding. The documentation does not support the IV fluids the member received were administered to address a nutrition need.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee between May 13, 2020 and May 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for eyeglasses provided on July 12, 2021.  You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says your Plan does not have out of network coverage.    Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by a network optical provider  We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by a network optical provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on July 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services provided to the enrollee on April 28, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says these services are considered inclusive to other codes.  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 the denied codes is:  CPT 43621:  Gastrectomy, total; with Roux-en-Y reconstruction  CPT 43659:  Unlisted laparoscopy procedure, stomach  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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the medical records provided does not include sufficient documentation to validate 43621-51, as it included in services performed with 43659; therefore, no additional reimbursement is allowed. The medical records provided does not include sufficient documentation to validate that 43659-51 was performed on April 28, 2021; therefore, this procedure cannot be verified.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services provided to the enrollee on April 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the knee arthroplasty to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no network deficiency 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 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 to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance services (A0429) and ground mileage (A0425) provided February 18, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that it was not your fault that you required an ambulance trip. The Plan denied your request. The Plan says you were charged this cost sharing 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 $150 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $150 for these services. 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 ambulance services (A0429) and ground mileage (A0425) provided February 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a MyoPro Orthosis.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of multiple sclerosis/neuromyelitis optica. There is insufficient peer-reviewed literature to support the use of the MyoPro Orthosis for these diagnoses. The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (97110) provided on October 19, 2020.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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.  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 services. Our reviewer says that the use of code 97110 is not supported by the records provided. Our reviewer found that the services were performed by a physical therapy assistant in the home, as the documentation supports the enrollee is homebound. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code to report for this service.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (97110) provided on October 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a left total knee arthroplasty.  You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says there is no updated documentation of further conservative measures, or if the measures have been evaluated, attempted, or successful.  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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no recent exams provided for review. The 12/9/20 exam notes bilateral knee pain for the past 2 years with average daily pain rated as a 1 on a scale of 0 to 10. He is noted to have tried NSAIDs, physical therapy and steroid injections. There is noted benefit with cortisone injections that lasted about 6 months on last injection. This does not corroborate failure of conservative measures, as there is noted benefit from those treatments. Additionally, detailed documentation is not evident regarding any viscosupplementation injections having been tried. Moreover, exam is almost 1 year ago, and updated findings would be needed to establish the medical necessity of the requested surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for left total knee arthroplasty 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a left total knee arthroplasty.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 28, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there is no network deficiency for these services and alternate network providers were found.  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 rendering 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 laboratory services provided to the enrollee on January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics (L3020).  You asked the Plan to pre-approve foot orthotics. You say that this is necessary due to the condition of the enrollee's feet. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that the enrollee does not suffer from diabetic foot disease or wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a duplex scan of lower extremity arteries or arterial bypass grafts provided on July 22, 2019.  You asked the Plan to pay for a duplex scan of lower extremity arteries or arterial bypass grafts. The Plan denied your request. The Plan says a corrected claim was received past the allowed 12-month timeframe.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for a duplex scan of lower extremity arteries or arterial bypass grafts was not filed until August 10, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for a duplex scan of lower extremity arteries or arterial bypass grafts provided on July 22, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pre-approve a crown - porcelain fused to predominantly base metal (D2751) for tooth 18.  You asked the Plan to pre-approve a crown for tooth 18. You say that a crown should be covered for tooth 18. The Plan denied your request. The Plan says that you do not meet criteria for a crown.  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. In this case the photocopies of x-rays forwarded were insufficient for review. We requested diagnostic quality x-rays and did not receive a response from the Plan. Without these x-rays we were unable to determine that criteria for the requested crown are not met.  Therefore, we decided that the Plan has to pre-approve a crown - porcelain fused to predominantly base metal (D2751) for tooth 18.   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.