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

We decided that the Plan does not have to pay for the complete mandibular denture received on May 5, 2021.

You asked the Plan to pay for the complete mandibular denture. You say that you would like a little help paying for this item. The Plan denied your request. The Plan says the item received is not a covered benefit.

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 complete mandibular denture received on May 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services of home health/hospice aide in home health or hospice settings coded G0156 provided on January 4, 2021 to May 1, 2021

You asked the Plan to pay for the services of home health/hospice aide in home health or hospice settings. 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. 

In this case, the CPT Code Manual definition of code G0156 is services of home health/hospice aide in home health or hospice settings, each 15 minutes.

We find that CPT code G0156 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of note and time was not documented. Based on this information, we decided that Medicare rules for coverage of the services of home health/hospice aide in home health or hospice settings have not been met. Therefore, we decided that the Plan does not have to pay for the services of home health/hospice aide in home health or hospice settings coded G0156 provided on January 4, 2021 to May 1, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).

You asked the Plan to pre-approve an upper denture. You say that the enrollee was unhappy with the previous denture she had made and did not even bring it home from the provider's office. The Plan denied your request. The Plan says one denture may be covered every five plan years. The Plan previously paid for the same type of complete upper denture in December of 2020. Therefore, this service is denied.

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 can cover one complete upper denture every five plan years. 

Though the Plan offers a dental benefit in excess of Medicare coverage, denture is requested in a frequency that is not covered under this benefit. Documentation shows that the Plan paid for this same type of denture in December 2020. Documentation shows that the enrollee did in fact refuse the dentures, however they were still covered and paid for by the Plan. The record also shows that the enrollee refused to have plan-covered corrections applied to the previous dentures. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that Orthovisc is covered when specific criteria are met. 

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She was previously treated with Synvisc injections over six months ago that were not helpful. Viscosupplementation is not reasonable or medically necessary when a repeat series of injections is administered when there was no symptomatic or functional improvement from a previous series. The requested Orthovisc is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure you had at an outpatient hospital facility on March 17, 2021.

You asked the Plan to waive the copayment for the arthrocentesis procedure. You say that the bill was originally sent to Medicare in error but then sent to the Plan and denied. You would like the Plan to reconsider payment. The Plan denied your request. The Plan says you were charged this copayment correctly and that the claim was not denied. The Plan says that because the allowed amount for this service ($303.06) is less than your copayment obligation, you are responsible for the full allowed 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 $370 copayment for surgery or other services in an outpatient hospital.

You have been asked to pay a $370 copayment for the arthrocentesis procedure. The arthrocentesis procedure falls within the surgery or other services in an outpatient hospital 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 arthrocentesis procedure you had at an outpatient hospital facility on March 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology exam of tissue provided on June 7, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the pathology exam of tissue. You say that the enrollee did not go to the laboratory because the participating doctor sent the specimen to process. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows the referring provider is out-of-network. Therefore, we decided that the Plan does not have to pay for the pathology exam of tissue provided on June 7, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for emergency care and a nasal/sinus endoscopy provided from February 23, 2021, to April 27, 2021.

You asked the Plan to waive the copayments for emergency care and a nasal/sinus endoscopy. You say that you disagree with the difference in 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 $90 copayment for emergency care. Your contract with the Plan also clearly says that you must pay a $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You received emergency care on February 23, 2021. Therefore, you are responsible to pay the $90 copayment. 

You received a nasal/sinus endoscopy on April 27, 2021, at an outpatient hospital facility. Therefore, you are responsible to pay the $250 copayment. 

The total amount you owe is: $340. 

You have been asked to the total copayment amount of $340 for emergency care and a nasal/sinus endoscopy. Emergency care falls within the emergency care benefit category. A nasal/sinus endoscopy 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 copayments for emergency care and a nasal/sinus endoscopy provided from February 23, 2021, to April 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on November 24, 2019.

You asked the Plan to pay for the therapy services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that the services of a 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 physical 
therapy 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 the therapy services represented by code 97110 provided on November 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prochlorper tablets.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.

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 Prochlorper tablets.

Benefits for these services 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 the enrollee's heard rate has been unstable, blood pressure elevated, and the enrollee has an infection. You state the enrollee would greatly benefit from rehabilitation therapy to aid the enrollee's recovery and to get them back to their home. The Plan denied your request. The Plan says the stay is not medically necessary.
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 there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on May 26, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on May 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ankle foot orthosis to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the orthosis. You say that this is medically necessary. The Plan denied your request. The Plan says that there are in-network provider(s) within a reasonable distance from your location that can provide this service or item.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an ankle foot orthosis to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on April
13, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that your primary care doctor
instructed you to take a medication that exacerbated your ulcer. You stated that this caused you to not be able
to stand up, so you called an ambulance. You stated that you should not have to pay this copayment because if
you had not taken the medication, you would not have needed the ambulance. 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 $250
copayment for ambulance services.

You have been asked to pay a $250 copayment for the ambulance services. This copayment applies regardless
of the reason for the ambulance 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 waive the copayment for ambulance services you received on April 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist arthroscopy represented by code 29844-59 provided on April 8, 2021.
You asked the Plan to pay for code 29844-59. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 29844 with modifier -59.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the procedure was not performed through a separate incision/excision site. The medical records received do not support that the procedure or service was distinct or independent from other services
performed. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the wrist arthroscopy represented by code 29844-59 provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a surgeon on April 27, 2021.

You asked the Plan to waive the copayment for the office visit with a surgeon. You say that you cannot afford this and you don't believe this doctor should be paid. You say that the medical records from this visit are not accurate. 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 $45 copayment for visits with a specialist. 

You have been asked to pay a $45 copayment for the office visit with a surgeon. This copayment applies regardless of your satisfaction with the 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 office visit you had with a surgeon on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network (OON) provider on March 30, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service.

Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network (OON) provider on March 30, 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) and subcutaneous injection of FDA nutri-pharmaceutical blend provided October 15, 2021
You asked the Plan to pay for electrical cell stimulation and injections. You say that it is your position that this treatment is medically necessary and appropriate for this enrollee's medical condition. The Plan denied your request. The Plan says the clinical value and effectiveness of electrical cell stimulation and the subcutaneous injection of FDA Nutri-Pharmaceutical blend in the setting of chronic pain syndrome and shoulder pain has not been proven.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electrical cell stimulation and injections have not been met. Therefore, we decided that the Plan does not have to pay for Sanexas neoGen-Series Therapy (electrical cell stimulation) and subcutaneous injection of FDA nutri-pharmaceutical blend provided October 15, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 8, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on June 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan 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 physician services provided on June 9, 2021 by an out-of-network (OON) provider.