Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78815) provided on August 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the diagnostic service. You say that you have attached the necessary medical documentation supporting the service and procedure performed. Please review and adjust the denied claim accordingly. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78815) provided on August 11, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), root canal (D3330), and cone beam computed tomography (CT) (D0380) provided on August 5, 2021.
You asked the Plan to pay the in network rate for the dental services. You say that you had to see whichever provider could get you in. You say that you just had a hip replacement. You say that you did not want the infection to spread. You also say that you feel the services should be covered at the in network rate. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that there is a 50% coinsurance for root canals. The Plan says that out of network dentist may bill you for any amount greater than what the Plan pays the provider. The Plan also says that cone beam CT 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 and the limited oral exam and root canal are listed as covered, there is a 50% coinsurance for root canals. Out of network providers may bill you for any amount greater than what the plan pays. Additionally, the cone beam CT is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), root canal (D3330), and cone beam computed tomography (CT) (D0380) provided on August 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on
August 12, 2021.
You asked the Plan to pay for the abdominal ultrasound. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 76705 has an edit with CPT code 93976.
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 76705 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 abdominal ultrasound (76705) provided on August 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the requested IRF services are medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of IRF services.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found there are no complex nursing or rehabilitation needs. The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this member will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional physical therapy visits.
You asked the Plan to pre-approve the 6 additional physical therapy visits. You say that you would like reconsideration because the additional physical therapy is medically necessary. The Plan denied your request. The Plan says the additional 6 physical therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the 6 additional physical therapy 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 you have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program. The requested services are not part of a maintenance program. 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 6 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the walker you received on August 3, 2021.
You asked the Plan to waive the coinsurance for the walker. You say that you were told this would be covered in full. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment. You have been asked to pay 20% coinsurance for the walker. The walker falls within the durable medical equipment 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 the walker you received on August 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery you had at an ambulatory surgery center on July 8, 2021.
You asked the Plan to waive the copayment for the cataract surgery. You say that you did not know there would be a copayment for this service. 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 $100 copayment for outpatient surgery. You have been asked to pay a $100 copayment for the cataract surgery. The cataract surgery falls within the outpatient surgery 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 cataract surgery you had at an ambulatory surgery center on July 8, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas neoGen Series Therapy (electrical cell stimulation) provided to the enrollee on June 22, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says experimental or investigational services are not covered
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a systemic disease causing his chronic pain and so electrical cell stimulation is not supported. Also, this specific product is not sufficiently supported by current evidence to be used for this enrollee's specific clinical condition. Therefore, this request for Sanexas neoGen Series Therapy (electrical cell stimulation) will be considered not medically necessary at this time. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for Sanexas neoGen Series Therapy (electrical cell stimulation) provided to the enrollee on June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown for tooth #4 provided on August 24, 2021.
You asked the Plan to pay for the crown. You say that you want 40% or 50% paid because they haven't covered anything yet. You say that you want to why they only paid the cheapest dental service. The Plan denied your request. The Plan says the $1,000 annual dental maximum was reached.
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 also have a maximum benefit of $1,000 per calendar year for covered dental services. The plan paid for the crown for tooth #2 provided on August 24, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the crown for tooth #4 provided on August 24, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on August 15, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the home visit. You say that 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. 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 the home visit provided on August 15, 2021, by an 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, the ankle strapping, and the radiologic examination provided on April 13, 2021, to May 5, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit, the ankle strapping, and the radiologic examination. You say that you did not know you needed pre-authorization for out-of-network services. 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 services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit, the ankle strapping, and the radiologic examination provided on April 13, 2021, to May 5, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the motorized wheelchair provided on July 28, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you were not satisfied with the Plan-approved wheelchair. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 motorized wheelchair provided on July 28, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided July 2, 2021.
You asked the Plan to pay for the ambulance. You say that you did not request an ambulance and payment for ambulance charge was outrageous. You're not seeking total payment but feel the insurance should cover some of the charge. The Plan denied your request. The Plan says this service is not covered under the Plan benefits.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 2, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided July 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) you had on February 22, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you wish to appeal this amount. 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 $150 copayment for diagnostic radiology services. You have been asked to pay a $150 copayment for the MRI. The MRI falls within the diagnostic radiology 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 magnetic resonance imaging (MRI) you had on February 22, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower bath chair and extra high toilet seat purchased out of network without prior authorization.
You asked the Plan to pay for these items. You say that your doctor told you that you needed to have these items. The Plan denied your request. The Plan says these items are not covered by Medicare and you did not have prior authorization for these purchases.
The Plan must follow Medicare rules. Medicare rules say that shower chairs and benches and raised toilet seats are not covered because they are not primarily medical in nature. While these items may be appropriate for your use, neither the Plan nor Medicare offers coverage for these items. Therefore, we decided that the Plan does not have to pay for a shower bath chair and extra high toilet seat
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from January 23, 2021, to February 23, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the copayment should be waived due to your coronavirus diagnosis. 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 $150 per day for days 1-5 and $0 per day for days 6-90 for each inpatient stay. The record shows you were in the hospital from January 23, 2021, to February 23, 2021. The record also shows your stay was not related to the coronavirus. Therefore, you have been asked to pay $150 per day for the first
five days of inpatient hospital services. The total for your stay is $750. Inpatient hospital services fall within the Inpatient Hospital Care 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 inpatient hospital services provided from January 23, 2021, to February 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises provided on January 20, 2021.
You asked the Plan to pay for the therapeutic exercises. You say that the patient was provided medically necessary services and the claim was processed incorrectly resulting in an adverse benefit determination. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code edit.
The Plan must follow Medicare rules. Medicare rules say that therapy services provided and billed incident to the services of a physician/NPP also must meet all incident-to requirements. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic exercises have not been met. Specifically, the billing provider is a physician assistant. As such, physical therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises provided on January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a second pair of eyeglasses provided on July 20, 2021.
You asked the Plan to pay for a second pair of eyeglasses. The Plan denied your request. The Plan says the eyewear benefit covers one pair of eyeglasses per calendar year.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and 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 the Plan covers one pair of eyeglasses per
calendar year. Therefore, we decided that the Plan does not have to pay for a second pair of eyeglasses provided on July 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myelography via lumbar injection procedure provided on August 27, 2021, at an outpatient hospital facility.
You asked the Plan to waive the copayment for the myelography via lumbar injection. You say that this was an additional and necessary procedure. The Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $275 copayment for outpatient surgery and other services at an outpatient hospital facility. The enrollee has been asked to pay a $275 copayment for the myelography via lumbar injection. The myelography via lumbar injection falls within the outpatient surgery and other services at an outpatient hospital facility 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 myelography via lumbar injection procedure provided on August 27, 2021, at an outpatient hospital facility.