Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for a physical therapy evaluation (97161) provided on October 29, 2019.
You asked the Plan to pay for a physical therapy evaluation. You say that this should be covered. The Plan denied your request. The Plan says this service exceeded the therapy limit.
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 code 97161 is not supported in the medical record. The therapy cap limit (combined PT and SLP) for 2019 was $2,040. Payment above this amount would only be payable if there were a KX modifier submitted with medical records to justify medically necessary care above the therapy cap. A KX modifier was not appended in this case. The procedure code at issue (97161) is subject to the therapy cap. Based on this information, we decided that Medicare rules for coverage of a physical therapy evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a physical therapy evaluation (97161) provided on October 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 25, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 laboratory services rendered on July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 20, 2019. You asked the Plan to pay for the office visit. 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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit provided on December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular junction testing coded 95937 provided on June 19, 2019.You asked the Plan to pay for the neuromuscular junction 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.In this case, the CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.We find that CPT code 95937 is not supported in the medical record. Specifically, the documentation does not support that neuromuscular junction testing was performed. Based on this information, we decided that Medicare rules for coverage of the neuromuscular junction testing have not been met.Therefore, we decided that the Plan does not have to pay for the neuromuscular junction testing coded 95937 provided on June 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 3 power wheelchair and accessories.You asked the Plan to pre-approvea Group 3 power wheelchair and accessories. You say that the facility staff is not always available to assist with mobility.The Plan denied your request. The Plan says power wheelchairs are not covered under Medicare for long term care facility residents.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that a Group 3 power wheelchair and accessories is being requested for use in a SNF.Therefore, we decided that the Plan does not have to pre-approvea Group 3 power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from October 21, 2019 to
October 25, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require 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 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 physician's services provided from October 21, 2019 to October
25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation, first intraoral periapical x-ray, and additional intraoral periapical x-ray provided on December 23, 2019.You asked the Plan to pay forthe periodic oral evaluation and intraoral periapical x-rays. The Plan denied your request. The Plan says these services are notcovered benefits.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 forthe periodic oral evaluation, first intraoral periapical x-ray, and additional intraoral periapical x-ray provided on December 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient psychiatric services provided on August 26, 2019 to August 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for inpatient psychiatric services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was 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 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. 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 inpatient psychiatric services provided on August 26, 2019 to August 28, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on December 4, 2019.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the $89.88 charge. 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 Medicare Part B prescription drugs. You received a Medicare Part B drug on December 4, 2019. The allowed amount is $449.40 and 20% of that is $89.88. You have been asked to pay the total coinsurance amount of $89.88 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 Medicare Part B drug provided on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran allergen injection provided on August 7, 2019 by an out of network (OON) provider.You asked the Plan to pay foran allergen injection. You say that you feel like you were taken advantage of because of your age and not knowing much about insurance.The Plan denied your request. The Plan says no prior authorization was 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 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. 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 foran allergen injection provided on August 7, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from July 1, 2019 to July 29, 2019.
You asked the Plan to pay for home health services. You say that the claim was denied in error. The Plan denied your request. The Plan says the service is not appropriate for the type of bill that was billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the claim must be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on the information provided, we decided that Medicare rules for completing the claim for home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from July 1, 2019 to July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 9, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 physician's services. 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 physician's services provided on November 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forfinger surgery provided on December 23, 2019.You asked the Plan to waive the copayment forfinger surgery. You say that this was a minimally invasive minor surgery. You say that your copayment is normally $20 or $30.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 $400 copayment for in-network, Medicare-covered outpatient hospital surgery services.You have been asked to pay a $400 copayment for the finger surgery. The finger surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the finger surgery was performed at the hospital. 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 forfinger surgery provided on December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) provided by a dental specialist on December 12, 2019. You asked the Plan to pay for the guided tissue regeneration. You say that you had an infection in the bone, and it had to be grafted. You also say that you do not know what the Plan covers or does not cover. The Plan denied your request. The Plan says this service is not a covered 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 guided tissue regeneration (D4266) provided by a dental specialist on December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvenerve blocks.You asked the Plan to pre-approvethe nerve blocks. You say that you would like reconsideration because this treatment has helped in the past.The Plan denied your request. The Plan says this service 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 nerve blocks. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is not evidence based therapy.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 nerve blocks have not been met.Therefore, we decided that the Plan does not have to pre-approvenerve blocks.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the ambulance transports provided on May 26, 2019 and May 29, 2019.
You asked the Plan to waive the copays for the ambulance transports. You say that you believed there was no copay. The Plan denied your request. The Plan says that the claims processed 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 $300 copay for each one-way Medicare-covered ground transportation service. You have been asked to pay a $300 copay for each of the ambulance transports. The ambulance transports fall within the one-way Medicare-covered ground transportation 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 copays for the ambulance transports provided on May 26, 2019 and May 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on June 23, 2018.
You asked the Plan to pay for the services provided. You say that you did not receive proper notice of the enrollee's benefit determination. The Plan denied your request. The Plan says the time limit for filing has expired.
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 provided was not filed until November 11, 2019. 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 medical services provided to the enrollee on June 23, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay the remaining cost forthe office visits provided on October 7,2019 and November 25, 2019.You asked the Plan to pay the remaining cost forthe office visits. You say that all your other doctor bills are paid for. You say that you are wondering why the bill isn't being paid.The Plandenied your request. The Plan says the copayments applied correctly.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them.The records show that you are only liable for $14.57 for each date of service. Therefore, we decided that the Plan does not have to pay the remaining cost forthe office visits provided on October 7, 2019 and November 25, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the psychotherapy visits provided from October 18, 2019 to November 25, 2019.
You asked the Plan to reduce the coinsurance for the psychotherapy visits. You say that you feel you should be reimbursed $280 for the out of-pocket amount you paid for the therapy visits. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 30% coinsurance per visit for out-of-network outpatient mental health care. You have been asked to pay $21 which is 30% of the allowed amount for each of the psychotherapy visits. The allowed amount is $70. ($70 x 30% = $21). The psychotherapy visits fall within the "Outpatient mental health care" benefit category. The record shows you were reimbursed the allowed amounts of the claims. ($70 x 4 = $196).
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 coinsurance for the psychotherapy visits provided from October 18, 2019 to November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis providedon November 11, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis. You say that the orthosis was medically necessary.The Plan denied your request. The Plan says the enrollee's medical record does not adequately support the medial necessity for the orthosis.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There are no medical records to support medical necessity for the orthosis. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis have not been met.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis providedon November 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe polycarbonate lens upgrade and protection plan purchased on November 8, 2019.You asked the Plan to pay forthe polycarbonate lens upgrade and protection plan. You say that  The Plan denied your request. The Plan says that these are not covered benefits.Medicare generally does not cover vision services. However, the Plan offers a vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a vision 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 forthe polycarbonate lens upgrade and protection plan purchased on November 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care from November 6, 2019 through
November 16, 2019.
You asked the Plan to pay for inpatient mental health care. You say that there was no payment on this claim
and this service was sudden and unexpected. The Plan denied your request. The Plan says the Medicare rules
have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of inpatient mental health care have not been met. A reasonable and
diligent effort was made by the staff to obtain the necessary medical records. No medical records were
provided to review this service. Therefore, we decided that the Plan does not have to pay for inpatient mental
health care from November 6, 2019 through November 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wound care supplies provided on April 24, 2019 by an out of network provider.You asked the Plan to pay forthe wound care supplies. You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request 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 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 has network providers available who can provide the items at issue in this appeal. The Plan did not pre-approve the itemsat issue. We found no exception that would require the Plan to pay for these items.Therefore,we decided that the Plan does not have to pay forthe wound care supplies provided on April 24, 2019by an out of network provider