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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), and prophylaxis (D1110) provided on May 24, 2021 by an OON provider.
You asked the Plan to pay for the dental services. You say that when you contacted the provider's office, the office person you spoke with told you that they accepted your insurance plan. The Plan denied your request. The Plan says these services are not covered benefits when they are rendered by a dentist who does not participate with the 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), and prophylaxis (D1110) provided on May 24, 2021 by an OON provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyewear provided on May 17, 2021.

You asked the Plan to pay an additional amount for the eyewear. The Plan denied your request. The Plan says
the Plan paid the maximum eyewear benefit for this calendar year.

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.

We looked at the file and the Plan's rules. The file shows that the Plan has paid the maximum eyewear benefit
amount of $100, and you are responsible for all costs over the allowance amount. Therefore, we decided that the Plan does not have to pay an additional amount for eyewear provided on May 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Donepezil Tab.
You asked the Plan to pre-approve Donepezil Tab. You say that the enrollee has failed on other drug
alternatives. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare
Part B drug benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pre-approve Donepezil Tab.
Benefits for Donepezil Tab 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 2, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 laboratory services provided on October 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation (RFA).
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 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 the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found RFA of the lateral sacral branches is considered experimental/investigational because of the wide
variation in efficacy reported in the literature. Therefore, the request is considered 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 sacroiliac joint radiofrequency ablation (RFA).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) care provided from January 30, 2021, through January 31, 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 services 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 a $0 copayment per day, for days 1-20 and a $184 copayment per day, for days 21-100 for skilled nursing facility care.

You have been asked to pay $368 ($184 copayment x 2 days) for the inpatient skilled nursing facility care provided. A claim for your stay in the skilled nursing facility from February 1, 2021, through February 22, 2021 was first received and processed by the Plan at a $0 copayment liability. An additional claim for dates of service January 30, 2021, through January 31, 2021 was received and processed by the Plan thereafter applying a copayment as these days of service were part of the skilled nursing facility stay. The Plan contract indicates that a copayment of $184 per day applies to skilled nursing facility care provided for days 21-100. You had a total of 23 days of care provided in this facility; however, you have no cost share liability for the day you were discharged. A copayment liability is indicated for days 21-22 of skilled nursing facility care provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) care provided from January 30, 2021, through January 31, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for colonoscopy with snare polypectomy, modifier to indicate preventative screening procedure (45385) provided April 8, 2021.

You asked the Plan to waive the copayment for the diagnostic service. You say that you were not informed that you had to pay a copay. You do not feel this should be your responsibility to pay this if you were not informed. The Plan denied your request. The Plan says this claim was processed with the correct copayments applied per the Evidence of Coverage.

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 $125 copay for each Medicare covered visit to an ambulatory surgical center. 

You have been asked to pay $125 copay for the diagnostic service. The diagnostic service falls within the Outpatient hospital service 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 colonoscopy with snare polypectomy, modifier to indicate preventative screening procedure (45385) provided April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99214) and pay for an eye refraction (92015) provided on May 17, 2021.

You asked the Plan to waive the copayment for an office visit and pay for an eye refraction. You say that you saw the provider for an annual eye exam, and you do not agree with the denial. The Plan denied your request. The Plan says the copayment you are being charged for the office visit is correct. The Plan also says that the eye refraction is not a covered benefit when it is not performed as a routine screening.

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 pay a $35 copayment per visit to an ophthalmologist or optometrist for Medicare-covered vision care. The Plan contract also says that an eye refraction is only covered by the Plan when it is performed as part of a routine screening by a participating provider. 

We looked at the file and the Plan's rules. The records show you had an office visit for an evaluation of a primary open-angle glaucoma (POAG). The EOC confirms $35 is the required copayment for that service. The records also show that the eye refraction was performed for medical vision purposes. An eye refraction is only covered by the Plan when it is performed as part of a routine screening. Based on this information, we decided that the Plan's rules for coverage of an office visit and an eye refraction have not been met. Therefore, we decided that the Plan does not have to waive the copayment for an office visit (99214) and pay for an eye refraction (92015) provided on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out of network oncology consultation.
You asked the Plan to pre-approve an out of network consultation. You say that you prefer to see the requested
provider. The Plan denied your request. The Plan says this 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 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 an out of network oncology
consultation with City of Hope
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on August 19, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
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 the services was not filed until April 21, 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 the services provided on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
February 17, 2021.

You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says services rendered by non-participating providers require prior authorization as outlined in the enrollee's Evidence of Coverage.

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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on February 25, 2021 by an
out-of-network provider.

You asked the Plan to pay for chiropractic manipulative treatment (98941, 98943). You say that you want the
Plan to pay this claim. The Plan denied your request. The Plan says you did not request prior authorization as
required.

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 services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for chiropractic services provided on February 25, 2021 by an out-of-
network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular profile (81406) provided on December 22, 2020.

You asked the Plan to pay for a hereditary cardiovascular profile. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular profile have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular profile (81406) provided on December 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient admission and services provided from March 5, 2021, to March 13, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that you cannot afford to pay this bill. The Plan denied your request. The Plan says the cost-sharing for these services was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $320 copayment for each of the first five days of an inpatient hospital stay. There is a $1,600 out-of-pocket limit for each stay.
You have been asked to pay a $1,600 copayment for eight days of inpatient care. 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 inpatient admission and services provided from March 5, 2021, to March 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiology services (73130, 73090) provided January 11, 2021.

You asked the Plan to pre-approve the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services are not separately payable.

The Plan must follow Medicare rules. Medicare rules say that for services that contain both a technical component and a professional component, the technical component, if any, must be billed by the Skilled Nursing Facility (SNF) for its Part A inpatients.

We looked at the file and Medicare rules. The enrollee was a part A inpatient at the time services were rendered. These services are not separately payable. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiology services (73130, 73090) provided January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on April 27, 2021.

You asked the Plan to pay for the dental guard. You say that these services are expensive, and you feel like more should be covered with your additional dental benefits. The Plan denied your request. The Plan says this service is not covered by Medicare or by your 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 the occlusal guard (D9944) provided on April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyewear provided on April 29, 2021.
You asked the Plan to reimburse you for eyewear. You say that you did not purchase the eyeglasses from the in-network provider because they wanted $630 for the exact same eyeglasses. The Plan denied your request. The Plan says the vision benefit allowance applies only to frames and lenses purchased by an in-network provider.
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 eyeglasses were not provided by a network optical provider. Based on this information, we decided that the Plan's rules for coverage of eyewear have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyewear provided on April 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport services on February 20, 2021.

You asked the Plan to pay for the ambulance response and treatment, no transport services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on February 20, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport services on February 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on April 1, 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 procedure code 97110 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. 

In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 

We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. 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 physical therapy services rendered on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infrared therapy you had on September 16, 2020.

You asked the Plan to pay for the infrared therapy. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that the use of infrared therapy devices and any related accessories is not reasonable and necessary. 

We looked at the file and Medicare rules. Per Medicare rules, the requested infrared therapy services are not medically reasonable and necessary, and therefore, not covered. Based on this information, we decided that Medicare rules for coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay for the infrared therapy you had on September 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on April 1, 2021.

You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not include a lab order for this testing.

The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. 

We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on April 1, 2021.