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

 We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on November 15, 2019.    You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.  The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, occupational therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on November 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an x-ray of the chest (71046) provided on July 29, 2021.  You asked the Plan to waive the copayment for x-ray of the chest. You say that the services should be covered as they were preventive due to past cancer. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $20 copayment for Outpatient diagnostic tests and therapeutic services and supplies.     You have been asked to pay a $20 copayment for an x-ray of the chest. x-rays fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. Based on the Plan's contract this $20 copayment applies regardless of whether the service is considered preventative. 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 an x-ray of the chest (71046) provided on July 29, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pre-approve scaling and root planing (D4341) for the lower left and lower right quadrants.  You asked the Plan to pre-approve the dental services. You say that these services are necessary. You also say that the services are required due to the amount of build up on your teeth and pockets that need to be managed. The Plan denied your request. The Plan says that the requested services are not medically necessary.  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 the dental services when the services are medically necessary and reasonable.  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 dental services. Our reviewer says that the request for scaling and root planing for the lower left and lower right quadrants meets the criteria for coverage. Our physician reviewer found the provided documentation indicates there are 4 to 6 mm pockets present in the lower left and right quadrants. Therefore, the reviewer found that the requested services meet the necessary criteria.  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 dental services have been met. Specifically, the file indicates there are 4 to 6 mm pockets present. Therefore, we decided that the Plan has to pre-approve scaling and root planing (D4341) for the lower left and lower right quadrants.   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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) provided on August 19, 2021.  You asked the Plan to pay for the intraoral periapical x-rays. You say that you went for a regular cleaning and nothing was explained to you about these services. You also say that you do not know what the purpose of these services was. The Plan denied your request. The Plan says these services are not covered expenses under your dental plan. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.  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 first intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network services provided to the enrollee on August 27, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 out of network services provided to the enrollee on August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office consultation to be rendered by the out-of-network (OON) provider.  You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.     The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office consultation to be rendered by the out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99204) and the radiologic examinations (72100 and 72040) provided on July 27, 2021.  You asked the Plan to pay for codes 99204, 72100, and 72040. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says codes 99204, 72100, and 72040 are not covered when billed by a chiropractor.  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. Therefore, we decided that the Plan does not have to pay for the office visit (99204) and the radiologic examinations (72100 and 72040) provided on July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).  You asked the Plan to pre-approve the total electric hospital bed. You say that the bed is medically necessary. The Plan denied your request. The Plan says this type of bed is not covered.  The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.   While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on November 6, 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.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal 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 the laboratory services provided on November 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on March 5, 2021.  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 March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a shower chair.  You asked the Plan to pay for a shower chair. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a bath/shower chair is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewing x-rays (D0274) and prophylaxis (D1110) provided on August 25, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the bitewing x-rays and prophylaxis. You say that you were advised that these services would be covered. The Plan denied your request. The Plan says these services are not covered benefits because they were rendered by a non-participating dentist.  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 OON. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) and prophylaxis (D1110) provided on August 25, 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 retreatment of previous root canal therapy - molar (D3348) provided May 11, 2021.  You asked the Plan to pay for the retreatment of previous root canal therapy. You say that you would like this service covered. The Plan denied your request. The Plan says this service is not covered under your 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 the retreatment of previous root canal therapy - molar (D3348) provided May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia services (99100) provided on December 18, 2020.  You asked the Plan to pay for anesthesia services. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified.   We looked at the file and Medicare rules. Code 99100 has a status indicator of B, meaning that payment for this service is bundled into payment for other services. Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided on December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on September 1, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network physician services provided to the enrollee on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the gynecology visit you had on June 15, 2021.  You asked the Plan to waive the copayment for the gynecology visit. You say that this was your annual well woman exam, so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for primary care visits.   You have been asked to pay a $15 copayment for the gynecology visit. According to your Evidence of Coverage, cervical and vaginal cancer screening services (i.e., Pap tests and pelvic exams) are covered with no copayment.  However, if you receive additional services beyond a Pap test and pelvic exam, an office visit copayment will apply.  We looked at the medical records from this visit.  While you may have received some of the screening services that are covered with no copayment, the records also show that your doctor did a full systems review, which is beyond the scope of a screening Pap test or pelvic exam.  That is why the office visit copayment applies. 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 gynecology visit you had on June 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (70551) provided August 13, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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, we have confirmed that code 70551 is a column II code to column I code 70553.   This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (70551) provided August 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for non-emergency transportation, wheelchair van provided on July 15, 2021.  You asked the Plan to pay for non-emergency transportation, wheelchair van. You say that this was an emergency, and you had to take your husband to the doctor's office because he had a foley on. You say that you had to use this provider for a stretcher because your husband could not get into a wheelchair. The Plan denied your request. The Plan says Medicare will not pay for transport by wheelchair vans because wheelchair vans are vehicles that do not meet the ambulance requirements.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services.   The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for non-emergency transportation, wheelchair van provided on July 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory work provided on July 16, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory work. You say that the patent was seen by an in-network physician with no control over the laboratory sued and should not be penalized. 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. The record shows there was no referring provider. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on July 16, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient mental health stay provided from June 26, 2020, to June 24, 2021.  You asked the Plan to pay for the acute inpatient mental health stay. You say that the enrollee was admitted on an involuntary commitment after he transferred from an inpatient acute mental health unit. You also say that the enrollee has suicide attempts in his past and there is significant concern about if he can sustain himself safely in the community. The Plan denied your request. The Plan says the services were not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 pay for the acute inpatient mental health stay. Our reviewer says that based upon review the records provided for the admission of this patient does not meet the criteria for acute inpatient mental health treatment. Our physician reviewer found it was not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any aggressive behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he did not have dangerousness to self or others, perceptual disturbance including auditory or visual hallucinations. Our reviewer found that this enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. Our physician reviewer also found that it did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis.  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 acute inpatient mental health stay have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient mental health stay provided from June 26, 2020, to June 24, 2021.