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

 We decided that the Plan does not have to pay for back and shoulder braces provided on May 29, 2021.  You asked the Plan to pay for back and shoulder braces. You say that you are appealing with the order, records, and delivery ticket which show these items were medically necessary and received by the enrollee. The Plan denied your request. The Plan says the denial of payment for these items is correct, because federal law prohibits telemarketing to Medicare beneficiaries.  The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.  We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of back and shoulder braces have not been met. Therefore, we decided that the Plan does not have to pay for back and shoulder braces provided on May 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services provided on May 12, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says prior authorization was not obtained.  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 provider in this case is not a network provider with the Plan. The referring provider 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 the drug testing services provided on May 12, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician attendance and supervision of hyperbaric oxygen therapy, per session (99183) provided August 4, 2021. 

You asked the Plan to pay for hyperbaric treatment. You say that please find medical notes to support date of service 08/04/2021. Please review and process the claim for payment. The Plan denied your request. The Plan says the records provided does not support medical necessity.  

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 pay for hyperbaric treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the items/services at issue in this case were not medically reasonable or necessary. The medical records provided did not meet the requirements listed in the NCD for Medicare coverage. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hyperbaric treatment have not been met. Therefore, we decided that the Plan does not have to pay for physician attendance and supervision of hyperbaric oxygen therapy, per session (99183) provided August 4, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for vision services (92250, 92202, 92020, 99213, 92285) rendered on June 28, 2021.  You asked the Plan to pay for vision services. You say that your physician rendered medical care for the patient as requested by the facility. The Plan denied your request. The Plan says that this provider is a non-participating provider, and the referring provider is a non-participating provider with the Plan. The Plan also says they did not authorize any services for this provider.  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. Specifically, the Plan has failed to forward a valid Evidence of Coverage for the services at issue. Without the contract from the Plan, we are unable to determine if Plan coverage criteria have been met. Please note, we requested this documentation from the Plan and did not receive a response. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for vision services (92250, 92202, 92020, 99213, 92285) rendered on June 28, 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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy services provided on April 9, 2021, and April 15, 2021 by an out-of-network (OON) provider.    

You asked the Plan to pay for the physical therapy services. You say that while your hospital strives to obtain authorization prior to treatment where practical, this was not the case for this account. You also say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says a referral was not received prior to these services being rendered.  

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 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 the physical therapy services provided on  April 9, 2021, and April 15, 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 vision care supply services (V2797) provided on July 26, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for vision care supply services. You say that you have purchased your eyeglasses in the past and never had an issue with payment from the Plan. The Plan denied your request. The Plan says for routine eyewear and routine eye exam, you must use an Insight network provider. 
 
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 gives the member a $200 allowance every year for covered eye wear purchased from a provider who participates in the Plan's specified vision network.  

We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. The Plan covers eyewear when they are received from a provider who participates in the Plan's specified vision network. Based on this information, we decided that the Plan's rules for coverage of vision care supply services have not been met. Therefore, we decided that the Plan does not have to pay for vision care supply services (V2797) provided on July 26, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the critical care services coded 99291 provided on May 25, 2021.  You asked the Plan to pay for the critical care services. 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 payable.  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 99291 is 1. The MAI value 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 critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on May 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to reduce the cost for cataract surgery provided on August 3, 2021, and August 10, 2021.  You asked the Plan to reduce the cost for the cataract surgery. You say that you paid $2,000 up front and the provider is only crediting $330. You say that you expect to be left with a total of $720 and be reimbursed for the remainder of the $2,000. The Plan denied your request. The Plan says the claims reprocessed to only apply a $360 copayment for each date of service.    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 $360 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.   You have been asked to pay a $360 copayment for each cataract surgery. The total amount you owe is $720 ($360/surgery x 2 surgeries = $720). Cataract surgery falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 reduce the cost for cataract surgery provided on August 3, 2021, and August 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Trelegy Ellipta (J3535).  You asked the Plan to pre-approve Trelegy Ellipta. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  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 pre-approve Trelegy Ellipta (J3535).   Benefits for Trelegy Ellipta 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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for a breast ultrasound provided on June 21, 2021.  You asked the Plan to waive the deductible for the ultrasound. You say that the procedure was preventative, not diagnostic. The Plan denied your request. The Plan says the correct amount was applied to your deductible.  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 there is $395 deductible which applies to certain items and services.   The ultrasound you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $395 deductible which applies to the ultrasound. This cost sharing is a contractual obligation that had not been met at the time the ultrasound was received on June 21, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a breast ultrasound provided on June 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex procedure for the enrollee.  You asked the Plan to pre-approve a Vertiflex procedure. You say that this procedure is medically necessary. The Plan denied your request. The Plan says this procedure is not covered by Medicare.  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 a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation is insufficient to support that the Vertiflex procedure is medically reasonable and necessary for the enrollee in this case. Current evidence-based clinical guidelines and peer-reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for the enrollee's medical condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical placements of implant bodies: endosteal implants (D6010) and precision attachments (D5862) provided on July 6, 2021.  You asked the Plan to pay for the endosteal implants and precision attachments. You say that the enrollee was under the impression that dental implants were covered under your supplemental buy up plan. The Plan denied your request. The Plan says your contract does not cover this service.  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 surgical placements of implant bodies: endosteal implants (D6010) and precision attachments (D5862) provided on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the filling (D2392) for tooth # 15 provided on June 23, 2021.  You asked the Plan to pay for the dental service. You say that you contacted the plan looking for a dentist that was close to your home. You say that you were given names of dental office and not specific dentists. You say that you were never told this provider was out of network. You also say that the service should be covered as you did everything on your end to make sure it would be. 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. Additionally, the filling is not a covered benefit regardless of the provider's network status. Therefore, we decided that the Plan does not have to pay for the filling (D2392) for tooth # 15 provided on June 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the gallbladder removal provided from August 20, 2021, through August 21, 2021.  You asked the Plan to waive the copayment for the gallbladder removal. You say that you had another gallbladder attack and it had to be removed. You say that you should be reimbursed the cost for each visit. The Plan denied your request. The Plan says the copayment 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 $350 copayment per date of service for outpatient surgery at an outpatient hospital facility.     You have been asked to pay a $350 copayment for the gallbladder removal. The gallbladder removal falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 gallbladder removal provided from August 20, 2021, through August 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiologic examination, chest (71046) provided May 13, 2021.  You asked the Plan to pay for the diagnostic service. You say that please review attached for medical necessity. The Plan denied your request. The Plan says does not meet Medicare NCD/LCD criteria.  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 71046 is radiologic examination, chest.  We find that CPT code 71046 is not supported in the medical record. Specifically, the enrollee received the services during or in preparation for a procedure or surgery at the facility. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for the radiologic examination, chest (71046) provided May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the frames and progressive lenses (sunglasses and eyeglasses) purchased August 25, 2021, from an out-of-network (OON) provider.  You asked the Plan to pay for the sunglasses and eyeglasses. You say that your plan allows you to go OON for a higher cost share. The Plan denied your request. The Plan says eyewear is not covered when provided OON.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are purchased from a vision network provider.  We looked at the file and the Plan's rules. The requested provider in this case is not a vision network provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of the frames and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for the frames and progressive lenses (sunglasses and eyeglasses) purchased August 25, 2021, from an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the progressive lenses provided on July 28, 2021.  You asked the Plan to pay for the progressive lenses. You say that you were unaware the provider was not contracted with the vision plan. The Plan denied your request. The Plan says you must receive your care from a network provider.  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 routine vision services when they are received from a network provider.  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the progressive lenses have not been met. Specifically, the lenses were not received from a Plan provider. Therefore, we decided that the Plan does not have to pay for the progressive lenses provided on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for four (4) gingival irrigations (D4921) and an adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431) provided on September 20, 2021.  You asked the Plan to pay for gingival irrigations and an adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities. You say that the services provided are all for cleaning and preventive maintenance. You thought this was included in your Plan for up to $1000 per year. You also say that you read the updates for this year and thought dental was increased. The Plan denied your request. The Plan says the services provided are 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, gingival irrigations and an adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities are not among those covered under this benefit. Specifically, any procedure code that is not listed, is not a covered benefit with your Plan. Therefore, we decided that the Plan does not have to pay for four (4) gingival irrigations (D4921) and an adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431) provided on September 20, 2021.