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

We decided that the Plan does not have to pay for the prophylaxis provided on January 20, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the prophylaxis. You say that you have been going to this dentist for 35 years. You also say that this service should be covered. The Plan denied your request. The Plan says this service was rendered by a Medicare opt out provider. The Plan also says that payment cannot be issued for services rendered by a provider who has opted out of Medicare.

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 by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on January 20, 2021 by a Medicare opt out provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a suspension sleeve (L2397) provided on November 4, 2020.

You asked the Plan to pay for a suspension sleeve. You say that the requested item is a necessity for the
enrollee's care. The Plan denied your request. The Plan says that rules for payment have not been met.

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 requested suspension sleeve is only covered when
accompanying a knee brace. The Plan has approved a knee brace. The Plan did not provide a rationale to
support why the knee brace is covered while the sleeve is not. Therefore, we decided that the Plan has to pay
for a suspension sleeve (L2397) provided on November 4, 2020.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for transvaginal ultrasound (76830) pelvic
ultrasound (76856) provided December 10, 2020.

You asked the Plan to waive the copayment for the diagnostic services. You say that you would like to know
what you need to do to dispute this charge of two studies at $220 because you advised them to notify you for
any amount due prior to the study. The Plan denied your request. The Plan says the claim was processed with
the correct copayment 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 $110
copayment for each Medicare covered radiological diagnostic service.

You have been asked to pay $220 ($110 + $110) for the diagnostic services. The diagnostic services fall within
the Outpatient diagnostic tests and therapeutic services and supplies 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 transvaginal ultrasound (76830) pelvic ultrasound (76856) provided December 10,
2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional PT visits.

You asked the Plan to pre-approve eight (8) additional PT visits. The Plan denied your request. The Plan says
eight (8) additional PT visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 eight (8) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally
accepted as specific and effective therapy for your condition beyond what was approved by the health Plan.
You have had prior therapy of ten (10) outpatient visits and the records do not demonstrate that the unique
skills of a professional therapist are required to safely and effectively provide treatment, that the services can
be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You were
authorized additional therapy to ensure competence in a home exercise program. The requested services are not
part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist
required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow
further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of eight (8) additional PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve eight (8) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the office visit (99214) provided on December 7, 2020.

You asked the Plan to waive the co-payment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the co-payment has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 co-payment for services provided by a specialty physician.

You have been asked to pay a $30 co-payment for the service provided by the specialty physician. 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 co-payment for the office visit (99214) provided on
December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composited (D2330), and the intraoral - periapical first radiographic image (D0220) received March 10, 2021.

You asked the Plan to pay for the dental services. You say that you were misled by the agent who told you your coverage would be the same as your medical coverage. The Plan denied your request. The Plan says the requested services are not covered under your supplemental 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 resin-based composited (D2330), and the intraoral - periapical first radiographic image (D0220) received March 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).

You asked the Plan to pre-approve the additional non-emergency transportation. You say that you received a
letter that your request for transportation extended trips were denied. The Plan denied your request. The Plan
says you have already received 48 one-way trips during the 2021 benefit period.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 48 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit and electrocardiogram provided on October 1, 2020.

You asked the Plan to pay for the emergency department visit (99285) and electrocardiogram (93010). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee was enrolled in hospice on the date of service.

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 the emergency department visit and electrocardiogram provided on October 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on March 1, 2021.

You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services 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 March 1, 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 services provided on March 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of daily complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient does not require the necessary services on an inpatient basis, in a SNF setting. The enrollee's needs are being met in the current inpatient rehabilitation facility (IRF) until the enrollee is ready for a home or community discharge.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator rental (K0606) rendered by the out of network (OON) provider on October 23, 2020.

You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the item 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 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 Plan had network providers available who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at issue.

We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator rental (K0606) rendered by the out of network (OON) provider on October 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered experimental.

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 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 Vertiflex procedure is experimental. More research is needed to show safety and efficacy of the device before coverage can be approved. 

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a partial lower denture (D5214) provided on June 30, 2020.

You asked the Plan to pay for a partial lower denture. You say that the previous partial lower denture was unacceptable to you.The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 5 Plan years.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a partial lower denture have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on May 10, 2017.Therefore, we decided that the Plan does not have to pay for a partial lower denture (D5214) provided on June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora partial upper overdenture (D5864) provided on February 11, 2021.

You asked the Plan to pay for a partial upper overdenture. You say that the service should be covered.The Plan denied your request. The Plan says the service at issue 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 a partial upper overdenture (D5864) provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology examination (72070), electrical stimulation
(G0283), and electric stimulation therapy (97014) provided March 5, 2020, to November 23, 2020.
You asked the Plan to pay for the radiology examination, electrical stimulation, and electric stimulation
therapy. You say that you would like these claims reprocessed and approved for payment as the provider was
in-network. The Plan denied your request. The Plan says the only covered chiropractic service is manual
manipulation of the spine to correct a subluxation.
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 services at issue are not manual manipulation of the spine. Although the provider is
in-network, these services are not covered by Medicare. Therefore, we decided that the Plan does not have to
pay for the radiology examination (72070), electrical stimulation (G0283), and electric stimulation therapy
(97014) provided March 5, 2020, to November 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an intermittent urinary catheter (A4353) provided on March 11, 2021.
You asked the Plan to waive the coinsurance for an intermittent urinary catheter. You say that the provider's charge for the item at issue is way too high. The Plan denied your request. The Plan says the correct coinsurance was applied.
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 durable medical equipment and related supplies.
You have been asked to pay $140.58, or 20% of the Medicare-allowed charge $702.90, for an intermittent urinary catheter. An intermittent urinary catheter falls within the "Durable medical equipment (DME) and related supplies" 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 an intermittent urinary catheter (A4353) provided on March 11, 2021.
Your complaint about the Plan overpaying for the item at issue 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: Imaging
Decision: Favorable

We decided that the Plan has to pay for the interpretation and report of the electrocardiogram (ECG) provided on January 7, 2021.

You asked the Plan to pay for the ECG interpretation/report. You say that this is a separately payable service. The Plan denied your request. The Plan says that another provider of the same specialty billed emergency room E/M services on the same date of service. No provider of the same specialty can be paid for an ECG interpretation on this date of service because this is bundled in payment for the emergency room E/M service.

The Plan must follow Medicare rules. Medicare rules say that providers can only be paid for a full interpretation and report of diagnostic testing, as a review of the findings is included in payment for the E/M service.

In this case, one provider billed only for E/M service. This provider did not bill for interpretation and report of the ECG. The record includes such a report from the billing provider at issue in this case. Review of the findings is included in the payment of the E/M services. This does not preclude payment of the actual interpretation/report done by a separate provider, regardless of the second provider's specialty. Therefore, we decided that the Plan has to pay for the interpretation and report of the electrocardiogram (ECG) provided on January 7, 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 waive the copayment for the physical therapy (PT) services provided February 18, 2021.
You asked the Plan to waive the copayment for the PT services. You say that you were scheduled for an evaluation for neck shoulder area. You were there for an hour and then received a $40 copay for physical therapy. You do not feel you owe a $40 copay and is disputing the copay. The Plan denied your request. The Plan says the claim was processed with the correct copayment 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 $40 copayment for each therapy visit. You have been asked to pay $40 copayment for the PT service. The PT service falls within the Outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the physical therapy (PT) services provided February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for thyroid stimulating hormone (TSH) (CPT code 84443) provided to the enrollee on September 2, 2020.

You asked the Plan to pay for the laboratory testing. You say that the claim should be paid.The Plan denied your request. The Plan says this service is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

CPT code 84443 is not a Medicare benefit for the diagnoses listed on the claim and is done for screening purposes. There is no documentation of a diagnosis for which this testing may be done on the claim form. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for thyroid stimulating hormone (TSH) (CPT code 84443) provided to the enrollee on September 2, 2020.