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

We decided that the Plan does not have to pay for the occupational therapy services rendered on May 27, 2020.
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 97530 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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We find that CPT code 97530 is not supported in the medical record. Specifically, the file shows 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 occupational therapy services rendered on May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care discharge provided on December 19,
2020, by an OON provider.
You asked the Plan to pay for the observation care discharge. You say that the provider was the on-call
physician during the observation stay. 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 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 observation care discharge provided on
December 19, 2020, by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy (90832) provided on January 22, 2021 by an out of network (OON) provider.

You asked the Plan to pay for individual psychotherapy. You say that claims denied due to internal error. Telehealth services provided under mental health outpatient benefit. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before 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 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 individual psychotherapy (90832) provided on January 22, 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 the extraction (D7210), the inhalation of nitrous oxide (D9230), and the consultation (D9310) provided on March 17, 2021.

You asked the Plan to pay for the dental services. You say that you received a pre-estimate for the services. You say that you paid $473 out of pocket for the services. You say that you are extremely unhappy with this experience. The Plan denied your request. The Plan says the extraction is not listed as a covered service. The Plan says that inhalation of nitrous oxide is not listed as a covered service. The Plan says that the consultation 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 dental services are not among those covered under this benefit. Additionally, the record shows that you signed a financial agreement showing that you agreed to the treatment estimate based on insurance information presented. Therefore, we decided that the Plan does not have to pay for the extraction (D7210), the inhalation of nitrous oxide (D9230), and the consultation (D9310) provided on March 17, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy (90834) rendered by the OON provider on January
19, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says that the service was rendered by an out of
network provider, 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 pay for care from either network or out-of-network providers, as long as the
services are covered benefits and are medically necessary.
The provider in this case is not a network provider with the Plan. The service provided was denied by the Plan
because prior authorization was not obtained. However, the Plan contract states that the enrollee can choose to
receive care from out-of-network providers. The plan will cover services from either network or out-of-network
providers, as long as the services are covered benefits and are medically necessary. Additionally, according to
the contract there is no referral or prior authorization necessary when the enrollee receives care from out-ofnetwork
providers. Therefore, we decided that the Plan has to pay for the psychotherapy (90834) rendered by
the OON provider on January 19, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel represented by code 81455 provided on September 2, 2020.
You asked the Plan to pay for code 81455. 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.
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. Medicare says that genetic testing submitted under code 81455 will be denied as not medically necessary as it is unlikely to impact therapeutic decision-making in the clinical management of the enrollee. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel represented by code 81455 provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (G0283) provided March 2, 2021.

You asked the Plan to pay for the electrical stimulation. You say that this service should be covered. The Plan denied your request. The Plan says this service is not covered under the chiropractic 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 electrical stimulation (G0283) provided March 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 30, 2020.
You asked the Plan to pay for the laboratory services. 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, the claim was billed with an incorrect place of service
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 30,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on December 28, 2020.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or pre-authorized.
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 service 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 an office visit (99214) provided on December 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from January 15, 2021 to January 19, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the self-administered drugs provided are not covered under your Medicare Part B 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 pay for the self-administered drugs provided from January 15, 2021 to January 19, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (tens) device represented by code E0730 provided on October 22, 2020.
You asked the Plan to pay for the tens device. 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. Medicare says that claims must specify whether equipment is rented or purchased. For purchased equipment, the itemized bill or claim must also indicate whether the equipment is new or used. The file shows that the claim was not billed with the appropriate modifier to indicate if the device was new or used. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (tens) device represented by code E0730 provided on October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on November 2,
2020.

You asked the Plan to waive the copayment for the eye exam. You say that this was a routine eye exam and
there should be no copayment. You say you only needed a prescription to replace your glasses. The Plan denied
your request. The Plan says you have been asked to pay 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 a $40
copayment for each Medicare-covered eye exam service.

You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the "Vision care"
benefit category. The record shows the provider billed the claim as a non-routine visit. 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 eye exam provided on November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for porcelain/ceramic crown (D2740) and core buildup services (D2950) provided January 20, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay more for porcelain/ceramic crown and core buildup services. You say that you were advised the provider was actually in-network sometime before August 2020. The Plan denied your request. The Plan says the claim processed correctly, and no additional payment is due.
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, you are responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay more for porcelain/ceramic crown (D2740) and core buildup services (D2950) provided January 20, 2021, by an out-of-network (OON) provider.
Your complaint about potentially receiving incorrect information regarding the in-network status of the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from October 20, 2020 to October 27, 2020.

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 the claim was billed incorrectly.

The Plan must follow Medicare rules. The rules state that the number of days of care charged to a beneficiary for inpatient hospital or skilled nursing facility (SNF) care services is always in units of full days. 

We looked at the file and Medicare rules. The file shows that the claim was incorrectly billed with 8 days/units of service; however, the date of discharge does not count towards the total number of days of service.

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 inpatient hospital services rendered from October 20, 2020 to October 27, 2020.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy (90834) rendered by the out of network (OON) provider on January 15, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the service was rendered by an out of network provider, 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 pay for care from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. The provider in this case is not a network provider with the Plan. The service provided was denied because prior authorization was not obtained. However, the Plan contract states that the enrollee can choose to receive care from out-of-network providers. The plan will cover services from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. Additionally, according to the contract there is no referral or prior authorization necessary when the enrollee receives care from out-of-network providers. Therefore, we decided that the Plan has to pay for the psychotherapy (90834) rendered by the out of network (OON) provider on January 15, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the acute inpatient rehabilitation admission provided from January 14, 2021, to January 29, 2021.

You asked the Plan to waive the copayment for the acute inpatient rehabilitation admission. You say that you were pre-approved for the rehab and were not advised you would have a $2,000 copayment. The Plan denied your request. The Plan says you have been asked to pay 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 a $400 copayment per day, days 1 to 5 and a $0 copayment per day, days 6 to 90 for inpatient hospital care.

You have been asked to pay a $400 copayment for each day, for days 1 to 5 of the acute inpatient rehabilitation admission. ($400 x 5 = $2,000). The acute inpatient rehabilitation admission falls within "Inpatient hospital care" 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 acute inpatient rehabilitation admission provided from January 14, 2021, to January 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient individual psychotherapy, 45-minute session (90834) provided on January 11, 2021 by an out of network (OON) provider.
You asked the Plan to pay for individual psychotherapy. You say that please reprocess claims. The claims denied due to internal error. Telehealth services provided under mental health outpatient benefit. The Plan denied your request. The Plan says non-emergent services with non-contracted providers require prior authorization before services being rendered.
The Plan must follow Medicare rules. Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare. The health plan contract on page 121 specifically says that prior authorization may be required for outpatient mental health 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 individual psychotherapy, 45-minute session (90834) provided on January 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 extraction, erupted tooth or exposed root (D7140) complete upper denture (D5110) complete lower denture (D5120) provided January 11, 2021 to February 8, 2021.
You asked the Plan to pay for the dental services. You say that you are appealing the denial for reimbursement for dental work you received. The Plan denied your request. The Plan says these services are not covered under the plan 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 for extraction, erupted tooth or exposed root (D7140) complete upper denture (D5110) complete lower denture (D5120) provided January 11, 2021 to February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the frames (V2020), the tint (V2744), the polycarbonate lens (V2784), and the progressive lens (V2781) received December 2, 2020.
You asked the Plan to pay an additional amount for the glasses after cataract surgery (V2744, V2020, V2784, V2781). You say that you were told you were eligible for a free pair of glasses. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 for Medicare-covered pair of eyeglasses after cataract surgery. The Plan contract says that enrollees pay $0 up to the Medicare allowable amount for a Medicare-covered pair
of eyeglasses after cataract surgery. You pay any amount over the Medicare allowable amount. The Plan agreed to pay up to the Medicare allowable amount of $215.13. You are responsible for any amount billed by the provider over and above the Medicare allowable amount. 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 pay an additional amount for the frames (V2020), the tint (V2744), the polycarbonate lens (V2784), and the progressive lens (V2781) received December 2, 2020.