Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466).

You asked the Plan to pre-approve the portable ventilator. You say that portable ventilator is necessary due to
severity of the enrollee's condition. The Plan denied your request. The Plan says portable ventilator is not
shown to be necessary; alternatives may work.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.

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 portable ventilator. Our reviewer
says that the service is not medically necessary. Our physician reviewer found there is no documentation to
suggest a BiPAP with back up rate and AVAPS was utilized. There is no record of supplemental oxygen or
positive airway pressure (PAP) device use. The documentation in the medical record does not support that the
ventilator at issue is medically necessary and reasonable for this enrollee. Alternatives may be more
appropriate.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the portable ventilator have not been met. Therefore, we decided that the Plan
does not have to pre-approve a portable ventilator (E0466).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after September 13, 2021.

You asked the Plan to pre-approve SNF care. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for continued SNF care after September 13, 2021 is correct.

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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for fundus photography provided on April 19, 2021.

You asked the Plan to waive the copayment for fundus photography. You say that you disagree with the additional $25 copayment. 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 $25 copayment for outpatient diagnostic procedures and tests. 

You have been asked to pay a $25 copayment for fundus photography. Fundus photography falls within the outpatient diagnostic tests and therapeutic services and supplies 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 fundus photography provided on April 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion test (the SPECT 
test) you had at an outpatient hospital facility on February 23, 2021. 
 
You asked the Plan to waive the copayment for the SPECT test. You say that you were not advised prior to the 
service what the cost was.  You said if you had known the cost, you would have declined the service. 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 $325 
copayment for diagnostic radiology services. 

You have been asked to pay a $325 copayment for the SPECT test. The SPECT test falls within the diagnostic 
radiology 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 myocardial 
perfusion test (the SPECT test) you had at an outpatient hospital facility on February 23, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to hold you harmless for the Regener-Eyes for dry eyes provided on March 24,
2021.
You asked the Plan to pay for the Regener-Eyes for dry eyes. You say that you cannot afford to pay for this
drug. The Plan denied your request. The Plan says that there are not enough studies on Regener-Eyes to show it
is safe and effective.
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 Regener-Eyes for dry eyes by a contract provider. The file does not show that the
Plan provided notice that the Regener-Eyes for dry eyes would not be covered. Under Medicare rules, this
means the Regener-Eyes for dry eyes is considered approved by the Plan. Therefore, we decided that the Plan
has to hold you harmless for the Regener-Eyes for dry eyes provided on March 24, 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 the scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on April 22, 2021.

You asked the Plan to pay for the scaling. You say that you were unable to see your dentist for 16 months and your teeth had deteriorated. You also say that you needed a deep cleaning, crown, core buildup, and you had several cavities. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

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 scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on April 22, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit. You say that you do not feel like you should be charged this much. You say that you were in the office for less than an hour. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available for these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for an office visit provided on April 22, 2021 by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on October 8, 2020.
You asked the Plan to pay for the hospital discharge day management. You say that physicians in the same group may bill without regard to the membership in the same group. You say that you do not agree with the original consideration. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
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 the hospital discharge day management provided on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the health club membership. 
 
You asked the Plan to pay more for the health club membership. You say that you sent the reimbursement in on 
time and the delay in mail is not your fault. You say that you should be reimbursed. The Plan denied your 
request. The Plan says the maximum amount of $150 was reimbursed and you are responsible for all charges 
over the $150. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers $150 each 
calendar year towards your cost for membership in a qualified health club or fitness facility. 

The Plan's rules for additional coverage of gym benefits have not been met because you have already been 
reimbursed the maximum amount of $150. Therefore, we decided that the Plan does not have to pay more for 
the health club membership.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a non-surgical visit in an outpatient clinic provided on December 4, 2020.

You asked the Plan to waive the coinsurance for a non-surgical visit in an outpatient clinic. You say that you did not know you would owe more than the $50 copayment and cannot afford the 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 20% coinsurance for a non-surgical visit in an outpatient clinic. 

The record shows that you had a non-surgical visit in an outpatient clinic on December 4, 2020. Therefore, you are responsible to pay your share of the cost-sharing charges. The allowed amount is $140.45 and 20% of that is $28.09. 

You have been asked to pay the total coinsurance amount of $28.09 for a non-surgical visit in an outpatient clinic. A non-surgical visit in an outpatient clinic 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 coinsurance for a non-surgical visit in an outpatient clinic provided on December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 28, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that the staff were rude at the doctor's office and you no longer will use this provider. You state that this was a follow-up visit with the physician. 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 $50 copayment for specialist office visits. 

You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls 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 copayment for a specialist visit provided on January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on August 6, 2020.
You asked the Plan to pay for the drug testing. 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 supported by the documentation.
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 codes 80307 and G0483 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on August 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share for the comprehensive oral evaluation (D0150), prophylaxis (D1110), the initial periapical x-ray (D0220), and the additional periapical x-rays (D0230 x 2) provided on April 2, 2021.

You asked the Plan to waive the out of network cost share for the oral evaluation, prophylaxis, and periapical x-rays. You say that when you enrolled in the plan, you were advised that it offered good benefits. You also say that you feel you were misled. 
The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that the plan pays according to a maximum allowable fee schedule, and you are responsible for all the fees in excess of this amount from the billed amount. The Plan also says that the claim was processed correctly.

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 the services are listed as covered, you might be billed for charges above what the plan pays, even for services listed as $0 copayment, for dental services you receive from an out of network dentist. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage.

Procedure code
Billed Amount
Allowed Amount
Plan Paid
Your Responsibility

D0150
$76.39
$31
$31
$45.39

D1110
$71.89
$48
$48
$28.89

D0220
$23.37
$13
$13
$10.37

D0230
$16.18
$9
$9
$7.18

D0230
$16.17
$9
$9
$7.17
TOTAL:
$94

Therefore, we decided that the Plan does not have to waive the out of network cost share for the comprehensive oral evaluation (D0150), prophylaxis (D1110), the initial periapical x-ray (D0220), and the additional periapical x-rays (D0230 x 2) provided on April 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245) and two retainer crowns (D6740 x2).

You asked the Plan to pre-approve the pontic and retainer crowns. You say that you do not have any molars and it is difficult for you to chew properly because you do not have enough teeth. The Plan denied your request. The Plan says these services 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6245) and two retainer crowns (D6740 x2).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from April 23, 2021, to
April 24, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you should not have to pay for these
denied charges because you did not receive any self-administered drugs while you were at the hospital. The
Plan denied your request. The Plan says self-administered drugs are not covered in the outpatient setting under
Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
provided from April 23, 2021, to April 24, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781) provided on March 25, 2021.
You asked the Plan to pay for progressive lenses. You say that you should not owe a bill because you paid out
of pocket at the vision center, and you were told these services would be covered. The Plan denied your
request. The Plan says you exhausted your $200 benefit allowance and 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 $200 allowance for supplemental eyewear every year.
We looked at the file and the Plan's rules. The records show you exhausted your $200 maximum allowed
benefit on March 25, 2021. The records also show that you purchased eyeglass frames at an allowed amount of
$83.60, photochromatic lenses at an allowed amount of $32.82, an anti-reflective coating at an allowed amount
of $47.80 and polycarbonate lenses at an allowed amount of $35.78. You received the total allowed amount of
$200 ($83.60 + $32.82 + $47.80 + $35.78 = $200). Based on this information, we decided that the Plan's rules
for coverage of progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay
for progressive lenses (V2781) provided on March 25, 2021
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus testing (U0004) provided on August 10,
2020.
You asked the Plan to pay for the laboratory testing. You say that the service should be covered. The Plan
denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in
which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the coronavirus testing (U0004) provided on August 10,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the radiation oncology visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the radiation oncology visit. You say that you need radiation as soon as possible and want to see a radiation oncologist that is closer to home. The Plan denied your request. The Plan says the provider is out-of-network

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. The record shows that although the referred in-network provider is 16 miles away, it is still within the Medicare-accepted distance. Therefore, we decided that the Plan does not have to pre-approve the radiation oncology visit to be provided by an out-of-network (OON) provider.