Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to reduce the cost sharing for inpatient hospital services you received from April 23, 2021, to April 28, 2021, from an out-of-network hospital.  You asked the Plan to reduce the cost sharing for the out-of-network hospital services. You say that you received conflicting information about the provider's network status. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan states that this hospital is out-of-network with your specific plan.  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 50% coinsurance for out-of-network inpatient hospital services.   You have been asked to pay 50% coinsurance for the out-of-network hospital services. 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 reduce the cost sharing for inpatient hospital services you received from April 23, 2021, to April 28, 2021, from an out-of-network hospital.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for CxBladder testing provided on March 4, 2021.  You asked the Plan to pay for CxBladder testing. You say that this testing provides actionable results that can make a meaningful difference in diagnosis and treatment of the enrollee. The Plan denied your request. The Plan says this testing is not covered by Medicare.    The Plan must follow Medicare rules. Medicare rules say that CxBladder code 0012M is not covered by Medicare.   We looked at the file and Medicare rules. This test is not covered. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing provided on March 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the paramedic intercept services provided on March 11, 2021.  You asked the Plan to pay for the paramedic intercept services. You say that you were told by the ambulance provider that you would not be charged for transportation but would be charged for the EMT services received. The Plan denied your request. The Plan says this item is not a covered benefit.  The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York.  The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494).  You asked the Plan to pre-approve the facet joint injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that facet joint injections are indicated if there is absence of untreated radiculopathy or neurogenic claudication.  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 facet joint injections. Our reviewer says that the injections are not medically necessary. Our physician reviewer found the record shows that the enrollee has neurogenic claudication.  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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64493, 64494).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for Biocept testing (88346, 88350) provided on May 3, 2021.  You asked the Plan to pay for Biocept testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that these is a non-coverage policy for all circulating tumor cells (CTC) assays.  We looked at the file and Medicare rules. The records indicate that the testing at issue was a CTC assay. Based on this information, we decided that Medicare rules for coverage of Biocept testing have not been met. Therefore, we decided that the Plan does not have to pay for Biocept testing (88346, 88350) provided on May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for two of the crowns (D2750) provided on January 21, 2021, and two of the fillings (D2393 x2) and unspecified preventative procedure (D1999) provided on March 10, 2021.  You asked the Plan to pay for the dental services. You say that you are frustrated with the confusion regarding which services are covered and you only approved work that would be covered to be done. The Plan denied your request. The Plan says only one crown and four fillings may be covered per calendar year. You previously had the maximum number of crowns and fillings covered this year. In addition, an unspecified preventative procedure 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. The Plan covers only services that are listed in the Plan's contract. The Plan can cover a maximum of four fillings per calendar year and one crown per calendar year.  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 or exceed the frequency limitations of the benefit. The unspecified preventative procedure is not listed as a covered service. Documentation shows that on January 21, 2021, the enrollee had 3 crowns. One of these was covered at this time. On March 10, 2021, documentation shows that the enrollee had six fillings. Four of these were covered at that time. Therefore, we decided that the Plan does not have to pay for two of the crowns (D2750) provided on January 21, 2021, and two of the fillings (D2393 x2) and unspecified preventative procedure (D1999) provided on March 10, 2021.   Your complaint about potential misinformation and billing issues from a Plan representative (contracted provider) is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency transport (A0429) and ground mileage (A0425) provided on February 16, 2021.  You asked the Plan to pay for the transportation services. You say that you feel the ambulance transport should be covered. You say that you cannot drive. You also say that it would have been difficult to get to be transported to the hospital if you did not call the ambulance. The Plan denied your request. The Plan says the transportation services were not medically necessary.  Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules.   We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation services have not been met. Specifically, the file does not indicate that the transportation services you received were emergent in nature. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, emergency transport (A0429) and ground mileage (A0425) provided on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the diagnostic mammography (77065) and breast ultrasound (76642) provided August 6, 2021 to August 25, 2021.  You asked the Plan to waive the copayment for the diagnostic services. You say that the tests were ordered as a follow up from a preventive mammogram and you would like these claims processed as preventive as well. The Plan denied your request. The Plan says the claims were processed with the correct copayments 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 $184.10 ($74.10 + $110) $80 copayment for diagnostic mammography in an outpatient hospital and $110 copayment for basic radiological services in an outpatient hospital for Outpatient diagnostic tests and therapeutic services and supplies.   You have been asked to pay $184.10 ($74.10 + $110) for the diagnostic services. For the diagnostic mammography, the allowed amount was $74.10 which is less than the copayment amount. Since the allowed amount was less than the copayment amount, you are responsible for the lesser amount. The diagnostic services 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 the diagnostic mammography (77065) and breast ultrasound (76642) provided August 6, 2021 to August 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the swallowing function test provided on May 5, 2021, and the speech therapy services provided from May 5, 2021, to May 18, 2021, while the enrollee was in a non-covered skilled nursing facility stay.  You asked the Plan to waive the copayments for the swallowing function test and the speech therapy services. You say that you asked to be contacted before therapy started so that you could review and approve it.  You said that the facility provided these services without your approval and did not provide you the results of the swallowing test. The Plan denied your request. The Plan says these copayments were 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 $10 copayment for diagnostic tests and a $35 copayment for rehabilitation therapy services provided in a skilled nursing facility during a non-covered stay.   The enrollee has been asked to pay a $10 copayment for the swallowing function test and a $35 copayment per session for the speech therapy services. The swallowing function test falls within the diagnostic tests provided in a skilled nursing facility during a non-covered stay. benefit category.  In addition, and the speech therapy services fall within the rehabilitation therapy services provided in a skilled nursing facility during a non-covered stay benefit category. This means that the enrollee has been asked to pay the correct amounts 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 copayments for the swallowing function test provided on May 5, 2021, and the speech therapy services provided from May 5, 2021, to May 18, 2021, while the enrollee was in a non-covered skilled nursing facility stay.   Your complaint about the facility not calling you with the results of the swallowing test to approve speech therapy is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a seat lift chair.   You asked the Plan to pre-approve a seat lift chair and seat lift mechanism. You say that this chair and mechanism are medically necessary. The Plan denied your request. The Plan says while the seat lift mechanism was approved, the upholstered chair often sold with the mechanism is not covered under Medicare.   The Plan must follow Medicare rules. Medicare does not cover the upholstered chair often sold with the seat lift mechanism. The Plan approved the seat lift mechanism. This means if you purchase an upholstered chair with an incorporated seat lift mechanism, the Plan will only pay for the mechanism as the upholstered chair is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on June 21, 2021.  You asked the Plan to pay for the dental services. You say that you found this provider on the website. You say that you called them and were advised they accepted your plan. You also say that you would not have gotten any services if you had not been approved. The Plan denied your request. The Plan says the provider in this case is not participating with the Plan. The Plan also says that care rendered by a provider that is not part of our supplemental dental network is not covered.  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 services are listed as covered, care rendered by a provider that is not part of our supplemental dental network is not covered. The record shows that the Dental Plan confirmed that the provider in this case does not participate with your plan. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on June 21, 2021.
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 March 23, 2020.    You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if 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 code 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 March 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on June 10, 2020.  You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the records submitted do not include progress notes needed to determine the clinical utility of this testing.  The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services.   We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. The Plan attempted to obtain notes from the ordering physician to determine why this testing was requested, but these records were not submitted. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on June 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Group 4 power wheelchair with accessories.  You asked the Plan to pre-approve Group 4 power wheelchair with accessories. You say that it is your professional judgment that the enrollee requires these items to be independent and safe with daily functional activities. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because a Group 4 power wheelchair is not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that a Group 4 power wheelchair will be denied as not reasonable and necessary, and therefore all related accessories will also be denied.   We looked at the file and Medicare rules. A Group 4 power wheelchair is not covered by Medicare. Since the base power wheelchair is not covered, the requested accessories are also not covered. Based on this information, we decided that Medicare rules for coverage of Group 4 power wheelchair with accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 4 power wheelchair with accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the podiatry visit you had on July 7, 2021.  You asked the Plan to waive the copayment for the podiatry visit. You say that the provider only cut your nails, so you should not have a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that the medical records confirm that you received more than just nail cutting during this visit.  The Plan says that the medical records show that you were also assessed for at-risk nails, onchymycosis, and peripheral vascular disease.  These services are beyond the scope of what is included with a routine 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 a $30 copayment per visit for podiatry services.   You have been asked to pay a $30 copayment per visit for the podiatry visit. 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 podiatry visit you had on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to fully pay for the eye exam and contact lens fitting provided on July 7, 2021.  You asked the Plan to fully pay for the eye exam and contact lens fitting. You say that you've had numerous issues regarding coverage with dental and now vision. You say that you are unsatisfied with the time you have spent fighting these coverage issues. The Plan denied your request. The Plan says the copayment applied correctly, and the contact lens fitting is not a covered benefit.  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. The Plan covers an eye exam with a $40 copayment and the contact lens fitting is not a covered benefit.  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eye exam and contact lens fitting have not been met. Specifically, the copayment applied correctly to the eye exam and the contact lens fitting remains denied as a non-covered benefit. Therefore, we decided that the Plan does not have to fully pay for the eye exam and contact lens fitting provided on July 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, a vertical shock reducing pylon feature.  You asked the Plan to pre-approve addition to lower limb prosthesis, a vertical shock reducing pylon feature. You say that the requested L5988 addition to lower limb prosthesis, a vertical shock reducing pylon feature is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested L5988 addition to lower limb prosthesis, a vertical shock reducing pylon feature.  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 addition to lower limb prosthesis, a vertical shock reducing pylon feature. Our reviewer says that the enrollee does not meet criteria for the requested L5988 addition to lower limb prosthesis, a vertical shock reducing pylon feature. Our physician reviewer found the enrollee underwent a right below-the-knee amputation on April 28, 2021, followed by a right-above-the knee amputation on May 19, 2021, secondary to peripheral vascular disease and tobacco abuse. The enrollee has active comorbidities of a left partial foot amputation, diabetes mellitus, and end-stage renal disease. The physician clinical office note dated June 24, 2021 does not detail the medical necessity for a vertical shock reducing pylon, states that the enrollee uses a wheelchair for mobility and states that the wound is in the healing phase with minor suture irritation with eschar along focused points on the incision. The progress note described future plans for the residual left lower extremity which include an arterial duplex with ankle brachial index (ABI). On June 4, 2021, it is documented that the enrollee has "Anticipated K2-3 potential." A vertical shock-reducing pylon feature is covered for enrollees whose functional level is 3 or above. It is not clear from the available documentation that the enrollee's functional level is 3 or above.  We looked at this physician's review, the file, and Medicare rules.   Based on this information, we decided that Medicare rules for coverage of addition to lower limb prosthesis, a vertical shock reducing pylon feature have not been met. Therefore, we decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, a vertical shock reducing pylon feature.