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

 We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on December 18, 2020.    You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contract 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 code is not appropriate for the service billed.  The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 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 physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay in full for the periodic oral evaluation (D0120), bitewing x-rays (D0274), first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), prophylaxis (D1110), topical application of fluoride varnish (D1206), anterior resin-based composite (D2330), and posterior resin-based composite (D2392) provided on August 30, 2021, and September 8, 2021 by out-of-network (OON) providers.  You asked the Plan to pay in full for the dental services. You say that before signing up with this plan you were told that the Plan allowed $1,000 worth of dental benefits per year and it did not matter if the dentist was in-network or OOON. You also say that you would like this claim to be paid in full. The Plan denied your request. The Plan says the total $992 amount applied correctly as your liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference between the billed amount and allowed amount for covered dental services received OON. Therefore, we decided that the Plan does not have to pay in full for the periodic oral evaluation (D0120), bitewing x-rays (D0274), first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), prophylaxis (D1110), topical application of fluoride varnish (D1206), anterior resin-based composite (D2330), and posterior resin-based composite (D2392) provided on August 30, 2021, and September 8, 2021 by out-of-network (OON) providers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional features for a prosthetic leg (L5828, L5925, L5850, L5845) for the enrollee.  You asked the Plan to pre-approve the features. You say that this is medically necessary. The Plan denied your request. The Plan says a request for prosthesis with a microprocessor knee does not meet Medicare criteria as reasonable and 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 features. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates the enrollee was approved for a power wheelchair recently, has a significant left hip flexion contracture, and uses an assistive device with a C leg. Therefore, the request for a K3 microprocessor knee exceeds his functional needs and is not medically necessary.  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 features have not been met. Therefore, we decided that the Plan does not have to pre-approve additional features for a prosthetic leg (L5828, L5925, L5850, L5845) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Nurtec 75mg ODT tablets.  You asked the Plan to pre-approve the Nurtec tablets. You say that this is a medically necessary drug. The Plan denied your request. The Plan says this oral medication is not covered by Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nurtec 75mg ODT tablets. Benefits for the Nurtec tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 you need more care in a SNF setting at this time because home health care cannot provide the amount of care you need to recover. You state that your family feels you need the SNF setting at this time. The Plan denied your request. The Plan says your records do not show you do not require skilled nursing services or skilled rehabilitation services on a daily basis, and which can only be provided on an inpatient basis in a SNF.   The Plan states your rehabilitation and medical needs can be met with part-time skilled services in a lower level of care, such as home with supervision and home health services. The Plan states home health services will need to be approved by your health plan. The Plan states your rehabilitation needs can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.  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 based on the medical records provided there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. You do require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient basis, only in SNF setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case.  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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for Turmeric Liquid purchased on October 27, 2021.  You asked the Plan to reimburse you for Turmeric Liquid. The Plan denied your request. The Plan says based on the members benefit plan and the Pick Your Perks program, turmeric is not a covered supplement or over the counter medication.  The Plan contract offers a supplemental Pick Your Perks program benefit. The benefit says over-the-counter items must be included on the Plan's allowed items list.  We looked at the file and the Plan's rules. The file shows that over-the-counter items must be included on the Plan's allowed items list. Ineligible items include but are not limited to the following: Alternative medicines such as botanicals, herbals, probiotics and nutraceuticals. Therefore, we decided that the Plan does not have to reimburse you for Turmeric Liquid purchased on October 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory work provided on July 17, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory work. You say that you were informed that your insurance would cover the service. 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 records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for laboratory work provided on July 17, 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 eyeglasses provided on June 15, 2021.  You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says you obtained services for deluxe frames through the Plan's vision benefit on June 9, 2021 and used your $100 vision reimbursement for this date of service.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at the file and the Plan's rules. The file shows that you obtained services for deluxe frames through the Plan's vision benefit on June 9, 2021 and used your $100 vision reimbursement for this date of service. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on March 10, 2021.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services are not supported.  The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.   We looked at the file and Medicare rules. The records provided do not contain medical records from the ordering provider, nor documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 10, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (76775) provided on September 18, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 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, we have confirmed that code 76775 is a column II code to column I code 93976. 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 the services (76775) provided on September 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure (CPAP) device and supplies provided from May 1, 2021, to July 1, 2021.  You asked the Plan to waive the coinsurance for the CPAP device and supplies. You say that you disagree with the charges and want the billing to stop. 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 a 20% coinsurance for durable medical equipment (DME), including CPAP supplies.     Item Allowed Amount 20% Coinsurance CPAP Chinstrap - June 14, 2021 $12.04 $2.41 CPAP Device - May 1, 2021 $58.48 $11.70 CPAP Device - June 1, 2021 $58.48 $11.70 CPAP Device - July 1, 2021 $58.48 $11.70 CPAP Pillow - June 14, 2021 $37.58 $7.52 Total:  $45.03  You have been asked to pay $45.03, which is 20% of the allowed amount for the CPAP device and supplies. The CPAP device and supplies fall 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 a continuous positive airway pressure (CPAP) device and supplies provided from May 1, 2021, to July 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the insertion of two electrodes for a permanent pacemaker provided on June 22, 2020.  You asked the Plan to waive the deductible for the insertion of two electrodes for a permanent pacemaker. You say that you had to have a repair done on your pacemaker and the wires were not cute properly so you have discomfort. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $110 deductible. Your contract with the Plan also clearly says that after the $110 deductible has been met, enrollee's must pay 15% coinsurance for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received the insertion of two electrodes for a permanent pacemaker on June 22, 2020, at an outpatient hospital facility. The insertion of two electrodes for a permanent pacemaker is considered an outpatient surgical procedure. The record shows that you had only paid $73.50 toward the $110 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible balance of $36.50. Now that the $110 deductible has been met, you are also responsible to pay 15% coinsurance on the difference between the allowed amount and the amount that applied toward the deductible. However, you are only being asked to pay $324.76, which is less than the total coinsurance amount. The total amount you owe is: $361.26.   The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $110 deductible which applies to outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time the insertion of two electrodes for a permanent pacemaker was received on June 22, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the insertion of two electrodes for a permanent pacemaker provided on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the removal of a permanent pacemaker provided on June 16, 2021.  You asked the Plan to waive the copayment for the removal of a permanent pacemaker. You say that you were told that the procedure would be covered in full. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for outpatient surgery, including services provided at hospital outpatient facilities.   You received the removal of a permanent pacemaker on June 16, 2021, at an outpatient hospital facility.  The removal of a permanent pacemaker is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $150 copayment.   You have been asked to pay a $150 copayment for the removal of a permanent pacemaker. The removal of a permanent pacemaker falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 removal of a permanent pacemaker provided on June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the precision attachment (D5862) and maxillary partial denture (D5213) provided on July 30, 2021, and August 17, 2021.  You asked the Plan to pay for the precision attachment and maxillary partial denture. The Plan denied your request. The Plan says the precision attachment is not a covered benefit under your dental plan. The Plan also says that your cost share was calculated correctly for the maxillary partial denture.  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, precision attachment (D5862) is not among those covered under this benefit. The contract says that you are responsible for a 50% coinsurance for a maxillary partial denture (D5213). Therefore, we decided that the Plan does not have to pay for the precision attachment (D5862) and maxillary partial denture (D5213) provided on July 30, 2021, and August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on September 30, 2021.  You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain/ceramic crown. You say that crowns are covered at 50% which is why you enrolled in this plan. The Plan denied your request. The Plan says these services are not covered under your plan.  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 custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on September 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance transportation provided on September 10, 2021.  You asked the Plan to waive the copayment for the ambulance transportation. You say that you were not given any option other than an ambulance. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment per day for ambulance round-trip services.   You have been asked to pay a $225 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 ambulance transportation provided on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the percutaneous tests (scratch, puncture, prick) with allergenic extracts coded 95004 and the intracutaneous (intradermal) tests with allergenic extracts coded 95024 provided on August 26, 2021.  You asked the Plan to pay for the percutaneous tests (scratch, puncture, prick) with allergenic extracts and the intracutaneous (intradermal) tests with allergenic extracts. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  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 find that CPT codes 95004 and 95024 are not supported in the medical record. Specifically, the documentation submitted did not include documentation of Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests; therefore, code 95004 cannot be verified. The documentation submitted did not include documentation of Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests; therefore, code 95024 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the percutaneous tests (scratch, puncture, prick) with allergenic extracts and the intracutaneous (intradermal) tests with allergenic extracts have not been met. Therefore, we decided that the Plan does not have to pay for the percutaneous tests (scratch, puncture, prick) with allergenic extracts coded 95004 and the intracutaneous (intradermal) tests with allergenic extracts coded 95024 provided on August 26, 2021.