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

We decided that the Plan does not have to pay for the eye exam and refraction provided on March 11, 2021.
You asked the Plan to pay for the eye exam and refraction. You say that your primary care physician, dental provider and lab testing are in the same office and there was never a billing issue. You say that you were not aware this specialist was not a participating in the network. The Plan denied your request. The Plan says care must be received from a network provider.
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 the eye exam and refraction provided on March 11, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your continued care can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our physician reviewer found that you have a past medical history of diabetes, end stage renal disease on hemodialysis, stroke, blindness, morbid obesity, lymphedema. You are receiving outpatient care for lower extremity cellulitis, an ulcer of the foot and lymphedema. You have progressive weakness and debility. Your medical conditions are stable. There is no documented need for acute inpatient medical care. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the magnetic resonance imaging (MRI) of the lumbar spine, without contrast (72148) and the magnetic resonance imaging (MRI) of the pelvis, without contrast (72195) provided on January 17, 2020.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 copayment for outpatient diagnostic tests. You have been asked to pay a $300 copayment ($114.44 + $185.56) for the outpatient diagnostic tests provided. 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 adjust the copayment for the magnetic resonance imaging (MRI) of the lumbar spine, without contrast (72148) and the magnetic resonance imaging (MRI) of the pelvis, without contrast (72195) provided on January 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the rebond of a crown (D2920) provided on March 3, 2021.
You asked the Plan to pay for the dental service. You say that you are unhappy that your plan does not cover comprehensive dental services. The Plan denied your request. The Plan says rebond of crown is not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the rebond of a crown (D2920) provided on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the closed treatment of posterior pelvic ring services coded 27197 provided on March 16, 2021.
You asked the Plan to pay for the closed treatment of posterior pelvic ring services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 27197 is closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; without manipulation.
We find that CPT code 27197 is not supported in the medical record. Specifically, this service was provided in the office location. This code has a non-facility status indicator of N/A which designates this to be a facility only service. This means this code not payable with the place of service billed. Based on this information, we decided that Medicare rules for coverage of the closed treatment of posterior pelvic ring services have not been met. Therefore, we decided that the Plan does not have to pay for the closed treatment of posterior pelvic ring services coded 27197 provided on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the ophthalmological medical examination and evaluation (92014), the scanning computerized ophthalmic diagnostic imaging (92134), and the external ocular photography with interpretation and report (92285) provided on January 6, 2021.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 $45 copayment for specialist physician services and a $50 copayment for all other Medicare covered outpatient diagnostic tests.
You have been asked to pay a $95 copayment ($45 + $50) for the specialist physician service and the Medicare-covered outpatient diagnostic tests provided. 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 adjust the copayment for the ophthalmological medical examination and evaluation (92014), the scanning computerized ophthalmic diagnostic imaging (92134), and the external ocular photography with interpretation and report (92285) provided on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical supplies provided on February 18, 2021.
You asked the Plan to pay for Alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. in. or less, each dressing (A6196). You say that the services rendered were medically necessary. The Plan denied your request. The Plan says additional payment should not be made for some supplies when billed on the same day as certain surgical procedures.
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, we have confirmed that code Alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. in. or less, each dressing (A6196) has a bundled relationship with code 11043 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the surgical supplies provided on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) provided February 24, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you had a conversation over the phone with a doctor and was told you had a $40 copay. You feel this copay should be waived because you were not told you were speaking with a specialist. 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 for each covered telehealth visit or consultation in an outpatient location with a specialist.
You have been asked to pay $40 for the office visit. The office visit falls within the Physician/Practitioner services, including doctor's office visits 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 outpatient office visit (99213) provided February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the palliative treatment of dental pain, minor procedure, (D9110) provided on January 12, 2021.
You asked the Plan to pay for the dental service. You say that the services that the enrollee received are clearly outlined covered dental services. You also say that the services should be covered. The Plan denied your request. The Plan says palliative treatment of dental pain is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the palliative treatment of dental pain is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the palliative treatment of dental pain, minor procedure, (D9110) provided on January 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency transport (A0429) and ground mileage (A0425) provided on October 25, 2019.
You asked the Plan to pay for the transportation services. You say that these services should be covered. The Plan denied your request. The Plan says the claim was received more than 12 months after the date of service. The Plan says that Medicare denies a claim if it is not received by the plan within 12 months or 1 calendar year from the date when the services were rendered.
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 transportation services was not filed until May 12, 2021. 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 emergency transport (A0429) and ground mileage (A0425) provided on October 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on April 8, 2021.
You asked the Plan to pay for a panoramic radiographic image. You say that you had an implant removed that caused a lot of problems. 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 panoramic radiographic image (D0330) provided on April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an actuator replacement (E2378), expandable controller replacement (E2376), a replacement hand or chin control interface, standard remote joystick (E2374) and controller shroud plastic black soft touch paint (K0108).
You asked the Plan to pre-approve these items. You say that you have been getting worse and these services are medically necessary. The Plan denied your request. The Plan says that these items cannot be replaced, as they are not present in the current wheelchair.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 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 actuator replacement, expandable controller replacement and a replacement hand or chin control interface, standard remote joystick. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. The requested items exceed your medical need. The documentation does not reveal that you require other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). You do not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. Your strength and function in the upper extremities with the ability to feed yourself supports that you can control any power options through their own individual switches. Our physician reviewer found that your condition does not meet criteria for coverage of an actuator replacement, expandable controller replacement and a replacement hand or chin control interface, standard remote joystick. We looked at this physician's review, the file, and Medicare rules. The controller shroud plastic black soft touch paint in this appeal does not serve a purpose that is primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not have to pre-approve an actuator replacement (E2378), expandable controller replacement (E2376), a replacement hand or chin control interface, standard remote joystick (E2374) and controller shroud plastic black soft touch paint (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on October 2, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was
submitted after the timely filing limit.
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 was not filed until April 15, 2021. 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 services provided on October 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan 
provided on March 7, 2021. 
 
You asked the Plan to waive the copayment for CT scan. You say that your copayment should only be $150 for 
the visit and not $150 per test. The Plan denied your request. The Plan says the copayment amount you are 
being charged is correct. The Plan also says that they have waived the second copayment, so you are only 
responsible for one $150 copayment for this visit. 
 
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 $150 
copayment per visit for CT scan.

You have been asked to pay $150 copayment for CT scan. CT scan falls 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 a Computed Tomography (CT) scan provided on March 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 18, 2021.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says with limited exceptions, the enrollee may be required to use network providers to get medical care and services. The only exceptions are emergencies, or urgently needed services when the network is not available.
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 February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection provided on January 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the injection. You say that you are asking for reconsideration of the charge for reimbursement. You say the service was medically necessary. 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 injection provided on January 18, 2021 by an out-of-network (OON) provider.
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. You say that the additional PT is medically necessary. The Plan denied your request. The Plan says the additional PT is not medically necessary and does not meet Medicare coverage criteria.
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 based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for your condition. Based on the latest available records you appear to have initially improved with therapy, but the most recent records indicate worsening pain. A detailed assessment of your current status and the plan for further therapy is not provided to justify the requested additional therapy. There is no documentation 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 under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is 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 pay for the anesthesia services provided to the enrollee on October 14, 2020, by an out-of-network provider.
You asked the Plan to pay for the anesthesia services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 the anesthesia services provided to the enrollee on October 14, 2020, by an out-of-network provider.