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

We decided that the Plan does not have to waive the copayment for IV hydration therapy, each additional hour (96361) IV hydration infusion, initial 31 minutes to 1 hour (96360) provided July 2, 2020 to July 16, 2020.

You asked the Plan to waive the copayment for the IV therapy services. You say that you have been receiving infusions for many years now and has never been billed for IV therapy only for your $10 copay. The Plan denied your request. The Plan says the claims were processed with the correct coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance per visit for IV therapy or transfusion services. 

The enrollee has been asked to pay $136.56 ($30.96 + $37.32 + $30.96 + $37.32 = $136.56) for the IV therapy services. The IV therapy services fall within the Outpatient hospital services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for IV hydration therapy, each additional hour (96361) IV hydration infusion, initial 31 minutes to 1 hour (96360) provided July 2, 2020 to July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crowns (D6740 x 2) and pontic (D6245)
provided on January 27, 2021.

You asked the Plan to pay for the bridge. You say that these services were medically necessary. You also say
that you would like to be able to chew on the right side of your mouth. The Plan denied your request. The Plan
says the bridge is not considered a preventive dental benefit. The Plan also says that the bridge is not covered
by 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
among those covered under this benefit. Additionally, the services you are asking the Plan to pay for involve
the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your
teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the
Plan does not have to pay for the retainer crowns (D6740 x 2) and pontic (D6245) provided on January 27,
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities, direct (one on one) patient contact by the provider (97530) provided May 26, 2020.
You asked the Plan to pay for the therapeutic activities. You say that many of the requested services in 2020 were not available on an outpatient basis secondary to the recent COVID-19 Virus pandemic. Please review all attached documentation supporting this request and process the claim for payment. The Plan denied your request. The Plan says the records do not support the billed service.
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 by the provider (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 records indicate that the service is performed by an occupational therapist assistant in a home health or hospice setting. There is an appropriate HCPCS code (G0158) for the billed service. The records show the plan made multiple attempts to contact the provider for the additional information without success. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities, direct (one on one) patient contact by the provider (97530) provided May 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a CPAP device provided on July 21, 2020, to January 21,
2021, by an out-of-network provider.

You asked the Plan to pay for a CPAP device. You say that you were not advised that the provider is out of
network. The Plan denied your request. The Plan says rules for out of network care have not been met.

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 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 a CPAP device provided on July 21, 2020, to January 21, 2021, by an out-of-network
provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for radiology services and physical therapy provided by a participating hospital facility on January 8, 2021, to January 15, 2021.

You asked the Plan to waive the co-payment for radiology services and physical therapy. You say that this was performed at a clinic and not a hospital. The Plan denied your request. The Plan says the correct co-payments have been applied.

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 $90 co-payment for outpatient diagnostic tests/in-network/radiology services/outpatient hospital and a $40 co-payment for outpatient rehabilitation services/in-network/physical therapy.

You have been asked to pay is $81.13 which is less than your co-payment amount of $90 for radiology services and a $40 co-payment for physical therapy. The total amount you are being asked to pay is $121.13 ($81.13 + $40 = $121.13). When a clinic is associated with a hospital, an outpatient hospital location charge is applied to the services that are provided; therefore, the correct co-payments have been applied. Radiology services falls within the outpatient diagnostic tests/in-network/radiology services/outpatient hospital benefit category and physical therapy falls within the outpatient rehabilitation services/in-network/physical therapy 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 co-payment for radiology services and physical therapy provided by participating hospital facility on January 8, 2021, to January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth visit (99214) provided on February 8, 2021.
You asked the Plan to pay for a telehealth visit. You say that this was billed correctly. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that providers should submit telehealth services claims using Place of Service (POS) 02-Telehealth to indicate they furnished the billed service as a professional telehealth service from a distant site. We looked at the file and Medicare rules. The telehealth service at issue was not billed with POS 02. Based on this information, we decided that Medicare rules for coverage of a telehealth visit have not been met. Therefore, we decided that the Plan does not have to pay for a telehealth visit (99214) provided on February 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2377, E2313, E2311, K0108).

You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary.The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the power seat elevation feature (E2300) is not covered by Medicare as it is not primarily medical in nature. The electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) do not meet criteria, as the enrollee has 3-3+/5 upper extremity strength and she is independent with feeding and grooming indicating she has adequate strength and function to control the power options with their own switches. The gel pads (K0108) do not meet Medicare criteria as records do not state why standard pads are inadequate for the enrollee.

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 additional accessories have not been met.Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2377, E2313, E2311, K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for out-of-network physician services provided October 28, 2020.
You asked the Plan to waive the copayment for the out-of-network physician services. You say that the services should be covered in full. The Plan denied your request. The Plan says the other dates of service were covered in full. These physician services were paid even thought they were out-of-network because they were urgent in nature. However, a copayment still applies.
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 $35 copayment for Specialist Visits. You have been asked to pay the allowable amount of $22.40 for the out-of-network physician services. The out-of-network physician services falls within the Specialist Visits benefit category. The allowable amount is less than the $35 listed in the Evidence of Coverage.
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 out-of-network physician services provided October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services provided by a participating provider on November 20, 2020.
You asked the Plan to waive the copayment for physician services. You say that this is not about the copayment, it is about the principle. The Plan denied your request. The Plan says the correct copayment has been 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 a $5 copayment for physician/practitioner services/in-network/primary care physician. You have been asked to pay a $5 copayment for physician services. Physician services fall within the physician/practitioner services/in-network/primary care physician 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 physician services provided by a participating provider on November 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance angiography (MRA) of the head (70544).You asked the Plan to pre-approve an MRA of the head. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that currently covered indications include using MRA for specific conditions to evaluate flow in internal carotid vessels of the head and neck, peripheral arteries of lower extremities, abdomen and pelvis, and the chest.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 an MRA of the head. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no explanation in the records for the request for MRA of the brain without contrast (cpt 70544) rather than the planned magnetic resonance imaging (MRI) of the brain (cpt 70551).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRA of the head have not been met.Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance angiography (MRA) of the head (70544).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain pontic (D6243) for tooth #30 and retainer
crown (D6740) for tooth #29.

You asked the Plan to pre-approve the pontic and retainer crown. You say that this request is for a replacement
for a bridge that was done 15 years ago. These teeth are already prepped, so a removable prosthesis will not
restore these teeth. The Plan denied your request. The Plan says a removable prosthesis or denture would be
more appropriate for this enrollee. The Plan has also approved porcelain/ceramic crowns (D2740) for teeth #28,
#29 and #31.

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. The Plan covers pontics and
retainer crowns when the services are medically necessary and reasonable. The Plan's rules also state that
bridges are only considered when documentation indicates there is a specific need or condition that precludes
the use of a removable prosthesis.

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 pontic and retainer crown. Our
reviewer says that the bridgework requested is not reasonable and necessary under the Plan's provisions. Our
physician reviewer found that there is no showing of any physical or neurological conditions that would
preclude the use of a removable appliance in this case. The health plan has approved crowns for teeth #31 and
#29, apparently in place of the three-unit bridge as the two abutments would require replacement. Although the
request is to replace an existing bridge, the Plan coverage limits bridgework to situations where a removable
appliance cannot be worn. A removable partial denture can be fabricated using the two adjacent teeth approved
for crowns as abutments. Given the Plan provisions, there is no medical necessity for the requested procedure.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the pontic and retainer crown have not been met. Therefore, we decided that the
Plan does not have to pre-approve a porcelain pontic (D6243) for tooth #30 and retainer crown (D6740) for
tooth #29.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening panel testing provided on December 15, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 
The test at issue in this appeal, genetic testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular screening panel testing provided on December 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is needed.The Plan denied your request. The Plan says the benefit has been exhausted.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 transportation 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 routine transportation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 23, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 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 services provided by an out-of-network provider on November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on February 11, 2021, by an OON
provider.

You asked the Plan to pay for office visit. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this service is correct, because this provider is
out-of-network with the Plan and 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 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 an office visit provided on February 11, 2021, by
an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenetic testing services provided on January 20, 2021.You asked the Plan to pay for the testing services. You say that the testing was deemed medically necessary.The Plan denied your request. The Plan says on CPT code must be submitted for the panel.
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 looked at the file and the rules. The testing services at issue were not billed with the correct CPT code and unit of service.Based on this information, we decided that Medicare rules for coverage of the testing services have not been met.Therefore, we decided that the Plan does not have to pay for the pharmacogenetic testing services provided on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. You say that this provider is in-network. The Plan denied your request. The Plan says the rendering provider is out-of-network. The Plan says that the member's primary care physician did not refer these services.
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 physician services provided on January 14, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425, A0429) received February 15, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that you had no choice but to transport via ambulance due to the weather and severity of illness. 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 $290 copayment for Ambulance Services. 

You have been asked to pay a $290 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance 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 ambulance transportation (A0425, A0429) received February 15, 2021.