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

We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on April 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay more for the comprehensive oral evaluation, complete series of intraoral x-rays, and prophylaxis. You say that all of the documents you received from the Plan indicate that you would be responsible for a $0 copayment for exams, cleanings, x-rays, and fluoride both in-network and out-of-network. You also say that you would like the remaining $270.00 to be paid by the Plan. The Plan denied your request. The Plan says the total $270.00 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 dental services that are received OON. Therefore, we decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on April 7, 2021 by an out-of-network (OON) provider.
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 December 12, 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 if services are not available 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, OTA 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 December 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three surgical placement of implant bodies: endosteal implants (D6010 x3) provided on May 3, 2021, and May 10, 2021.
You asked the Plan to pay for the endosteal implants. You say that these were replacements for lost teeth. You also say that you purchased the dental insurance to get your teeth fixed so you could eat your food properly. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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 three surgical placement of implant bodies:
endosteal implants (D6010 x3) provided on May 3, 2021, and May 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapist on December 11, 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 if services are not available 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 services of an occupational therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. 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. 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 therapist on December 11, 2019.
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 are not strong enough to go home yet. The Plan denied your request. The Plan says an intensive rehabilitation program is not medically necessary.
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation program. There is not a reasonable expectation that you 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on May 14, 2021.
You asked the Plan to pay for the bitewing x-rays. You say that you had 2 bitewing x-rays in the same year, but the first one was a specific image for a tooth that needed to be extracted. You also say that you would like the Plan to either pay the $64 for the routine bitewing x-rays, or at a minimum pay the difference of $38. The Plan denied your request. The Plan says the frequency limit for this service has been exceeded.
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, bitewing x-rays (D0270, D0272, D0273, D0274, and D0277) are limited to one procedure per plan year. The record shows that you received bitewing x-rays (D0270) on April 21, 2021 and your bitewing x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on May 14, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve bioimpedance spectroscopy (93702).
You asked the Plan to pre-approve bioimpedance spectroscopy. You say that this is medically necessary. The Plan denied your request. The Plan says that this is experimental.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 bioimpedance spectroscopy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found bioimpedance spectroscopy (BIS) is an increasingly utilized diagnostic technique that allows for the subclinical detection of lymphedema, prior to clinically evident disease. Early detection allows early treatment for prevention of clinically significant lymphedema. It has become a standard of care. Given the multiple surgeries of the right breast and radiation the patient is at risk of lymphedema. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bioimpedance spectroscopy have been met. Therefore, we decided that the Plan has to pre-approve bioimpedance spectroscopy (93702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the LTACH will offer the enrollee the
best opportunity for continued improvement. The Plan denied your request. The Plan says criteria for LTACH
admission have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found that the enrollee appears to be unstable currently and requires additional short-term
acute care services, such as treatment for percutaneous endoscopic gastrostomy (PEG) tube issue, that can
safely be completed at the current acute care facility. The enrollee does not require services at the LTACH that
are not already available at the current facility. There are no services at the LTACH that the enrollee requires
that are not already available and covered at the current facility. The LTACH services will be considered not
medically necessary as transfer would not provide any significant change in treatment. Transfer to a lower level
of care may be considered when treatment has completed.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoulder stretch therapy device (E1841).
You asked the Plan to pre-approve the stretch therapy device. You say that the enrollee requires this device. The Plan denied your request. The Plan says this device falls under the experimental and unproven and is not covered by your Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We asked our 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 stretch therapy device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our reviewer found the Plan has defined this device as experimental and investigational, therefore not covered. We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the stretch therapy device have not been met. Therefore, we decided that the Plan does not have to pre-approve shoulder stretch therapy device (E1841).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the services are medically necessary. The Plan denied your request. The Plan says there are not enough scientific studies to show that inserting a device to open the narrowed space would be safe and effective for the enrollee.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair provided by the store on May 19, 2021.
You asked the Plan to pre-approve a shower chair. You say that you we not informed you needed a prescription from your physician. The Plan denied your request. The Plan says this item is not a covered benefit.
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 pre-approve a shower chair provided by Walmart on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on May 25, 2021.
You asked the Plan to waive the copayment for arthrocentesis. You say that you did not have an office visit you just received and injection and disagree with the charges. 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 $30 copayment for specialist services. You received arthrocentesis on May 25, 2021, at a specialists office. Arthrocentesis is considered a surgical procedure and is subject to specialist charges. Therefore, you are responsible to pay the $30 copayment. You have been asked to pay a $30 copayment for arthrocentesis. Arthrocentesis falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for arthrocentesis provided on May 25, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2332) or pay more for the
surgical extraction (D7210) provided on March 9, 2021, by an OON provider.
You asked the Plan to pay for the resin-based composite and to pay more for the surgical extraction. You say
that you are covered under your policy for 45% of both of these procedures, and 45% is $235.80. The Plan
denied your request. The Plan says your benefits for the resin-based composite have been satisfied and the
frequency limitation has been exceeded. The Plan also says that these services were performed by a nonparticipating
provider, and you are responsible for any difference between the Maximum Allowable Fee and
the amount the provider bills you for the services.
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, restorations (fillings) are limited to two
procedure codes per calendar year. The record shows that you received two amalgams on April 1, 2021, and
your restorations benefit has been exhausted. The contract also clearly states that you must pay a 55%
coinsurance for the extraction, plus the difference between the billed amount and allowed amount for services
received OON. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2332)
or pay more for the surgical extraction (D7210) provided on March 9, 2021, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee is participating in therapies and is eligible for coverage of SNF care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of SNF care.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the enrollee requires skilled nursing services. The medical records provided show that the enrollee does require skilled therapy services, but that they are not required on a daily basis. The enrollee does not require the services on an inpatient basis, only in a SNF setting. Services 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance amount for the Ferumoxytol injections (Q0138) provided on May 21, 2021, and May 28, 2021.
You asked the Plan to reduce the coinsurance amount for the Ferumoxytol injections. You say that you were pre-authorized for this service, but were not made aware of the price you would have to pay. You also say that you had a much lower option you could have gone with. The Plan denied your request. The Plan says this claim processed correctly according to your benefit for Medicare Part B prescription drugs.
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 Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the Ferumoxytol injections. Ferumoxytol injection falls within the Medicare Part B prescription drugs 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 reduce the coinsurance amount for the Ferumoxytol injections (Q0138) provided on May 21, 2021, and May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit on March 25, 2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that you went to the practitioner and were informed he was unable to help you. You also state you were advised to go a different facility. 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 $25 copayment for each Medicare-covered specialist visit. You have been asked to pay a $25 copayment for a specialist office visit. Office visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit on March 25, 2021.
Your complaint about the billing services from the 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), surgical extraction (D7210), and placement of intra-socket biological dressing (D7922) provided on June 8, 2021 by an oral surgeon.
You asked the Plan to pay for the problem focused limited oral evaluation, surgical extraction, and placement of intra-socket biological dressing. You say that the general dentist could not pull the tooth due to your medical condition and referred you to an oral surgeon. You also say that you requested an authorization for the services but was denied. The Plan denied your request. The Plan says the supplemental dental services benefit of your contract only provides coverage for dental services when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon are 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, the requested items or services are not covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), surgical extraction (D7210), and placement of intra-socket biological dressing (D7922) provided on June 8, 2021 by an oral surgeon.