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

We decided that the Plan does not have to pay for the eyeglasses (V2203, V2784, V2781) provided on August 18, 2021.
You asked the Plan to pay for the eyeglasses. You say that this was an in-network provider and you do not understand how your benefit was exhausted at the time of service because you had not used it yet this year. The Plan denied your request. The Plan says this claim was processed correctly, and your benefit paid at the time of purchase. You are responsible for the cost of the eyewear that exceeded the $120 benefit allowance.
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 up to $120 per calendar year. We looked at the file and the Plan's rules. Documentation shows that the total cost of the eyeglasses was $219. The Plan paid $120 at the time of service, and you are responsible for the remaining $99. This means you have been asked to pay the correct amount based on your contract with the Plan and used your full routine eyewear benefit allowance at the time of purchase. Based on this information, we decided that the Plan does not have to pay any additional amount for the eyeglasses (V2203, V2784, V2781) provided on August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a tooth extraction (D7140) provided by an out-of-network provider on August 31, 2021.

You asked the Plan to pay for a tooth extraction. You say that this dental work should be covered because it was life threatening. The Plan denied your request. The Plan says D7140 is not a covered dental benefit.

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 a tooth extraction (D7140) provided by an out-of-network provider on August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Service(s) provided between 10:00pm and 8:00am at a 24-hour facility, in addition to basic service (99053) provided May 4, 2021.

You asked the Plan to pay for additional after-hours services. You say that the attached medical records support the claim as originally submitted. Please review the attached documentation for the enrollee's treatment. The Plan denied your request. The Plan says this procedure/service is not paid separately.

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, we have confirmed that code after hours services is a column II code to column I code 99285. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for Service(s) provided between 10:00pm and 8:00am at a 24-hour facility, in addition to basic service (99053) provided May 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the lumbar spine (72148) provided on August 23, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 up to a $50 copayment for each Medicare-covered diagnostic radiology service in an office setting or imaging center.
You have been asked to pay a $50 copayment for the Medicare-covered diagnostic radiology service provided in an imaging center. 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 magnetic resonance imaging (MRI) of the lumbar spine (72148) provided on August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete maxillary and mandibular denture set (D5110 and D5120) provided by an out-of-network provider on August 12, 2021.

You asked the Plan to pay for a complete maxillary and mandibular denture set. You say that you do not feel like you should have to pay for this. The Plan denied your request. The Plan says the enrollee is responsible for all cost over and above the allowance amount of $2,000.

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. The Plan covers a maximum allowance amount of $2,000 per year for supplemental comprehensive dental services.

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's has a maximum allowance amount of $2,000 per year for supplemental comprehensive dental services. The enrollees are responsible for all cost over and above the allowance amount. The total amount you are being asked to pay is $3,028. Therefore, we decided that the Plan does not have to pay for a complete maxillary and mandibular denture set (D5110 and D5120) provided by an out-of-network provider on August 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Osteocell Allograft 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 the requirement is a doctor's exam and advanced imaging within the last year showing nerve compression, or at least moderate narrowing of the space around the spinal cord or spinal nerves.
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 osteocell allograft remains experimental in cases of spinal surgery. More research is needed to show safety and efficacy. 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 Osteocell Allograft for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically
necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient cardiac rehabilitation provided on June 2, 2021, to June 11, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for outpatient cardiac rehabilitation. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained 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 outpatient cardiac rehabilitation provided on June 2, 2021, to June 11, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmic biometry (procedure code 92136) provided to the enrollee on February 24, 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 the units reported exceeds the medically unlikely units.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 92136 is 1. The MAI for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 ophthalmic biometry (procedure code 92136) provided to the enrollee on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), pulp vitality test (D0460), and root canal (D3310) provided on August 12, 2021, by the out of network dentist.
You asked the Plan to pay for the dental services. You say that your dentist advised that your tooth was up into a nerve and causing your pain. You say that your dentist recommended a root canal. You say that you have dental coverage. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan says that the frequency limit has been exceeded. The Plan says that pulp vitality test is not listed as a covered service. The Plan also says that out of network dentists may bill you for any amount greater than what the Plan pays.
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 limited oral evaluation is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan previously paid for this service that you received on August 11, 2021. Periapical x-ray and root canal are listed as covered, however out of network providers may bill you for any amount greater than what the plan pays. Additionally, pulp vitality test is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), pulp vitality test (D0460), and root canal (D3310) provided on August 12, 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 office visit (99203) provided to the enrollee on April 16, 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 an incorrect procedure code was used for an established patient.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99203 is "Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter." We find that CPT code 99203 is not supported in the medical record. Specifically, this enrollee would not be considered a "new patient" as they had seen a different provider with the same specialty and taxonomy within the past three years. 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 office visit (99203) provided to the enrollee on April 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pacemaker evaluation you had at a cardiology office on August 16, 2021.

You asked the Plan to waive the copayment for the pacemaker evaluation. You say that you have to go into the office every six months to recharge your pacemaker battery. You said that you had never been billed for this in the past. 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 $35 copayment for medical services in a specialist's office.

You have been asked to pay a $35 copayment for the pacemaker evaluation. This copayment applies regardless of what you may have paid in the past. 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 pacemaker evaluation you had at a cardiology office on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic biometry (92136) provided on June 22, 2021.
You asked the Plan to waive the copayment for ophthalmic biometry. You say that you were dissatisfied with the services provided and feel you should not be responsible for this cost. The Plan denied your request. The Plan says they are addressing your concerns in a separate grievance, but the copayment for this claim was applied in accordance with your contract.
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 Medicare-covered vision services. You have been asked to pay a $40 copayment for ophthalmic biometry. Ophthalmic biometry falls within the Medicare-covered vision 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 ophthalmic biometry (92136) provided on June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing (D4342) and gingival irrigation (D4921) provided on August 11, 2021.
You asked the Plan to pay for the dental services. You say that your dentist advised that you needed this specific type of cleaning. The Plan denied your request. The Plan says scaling and root planing is not listed as a covered service. The Plan says that gingival irrigation is not listed as a covered service either.
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 scaling and root planing, and gingival irrigation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the scaling and root planing (D4342) and gingival irrigation (D4921) provided on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laboratory services provided to the enrollee on
February 25, 2021.
You asked the Plan to pre-approve the services. You say that the provider ordered these labs, and you were not aware they were out-of-network. The Plan denied your request. The Plan says the services were provided by an out-of-network 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 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 laboratory services provided to the enrollee on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5255) provided on May 5, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for hearing aids. You say that you went to this particular provider because you have seen this provider in the past for your hearing aids. The Plan denied your request. The Plan says you are responsible for the services, as your Plan only covers in-network providers and this provider is OON.

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 provided by the Plan's hearing aid provider. 

We looked at the file and the Plan's rules. The file shows that the hearing aids were provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5255) provided on May 5, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 9, 2021.

You asked the Plan to pay for the services. You say that the denied charges are covered under a capitation agreement/managed care plan. The Plan denied your request. The Plan says the services were provided 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 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 laboratory services provided to the enrollee on February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV tubing extension set (S1015) and the infection control supplies (S8301) provided on June 3, 2021.

You asked the Plan to pay for codes S1015 and S8301. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. In this case, CPT codes S1015 and S8301 have a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. Medicare uses other codes for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pay for the IV tubing extension set (S1015) and the infection control supplies (S8301) provided on June 3, 2021.