Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 skilled nursing visits and 12 home health aide visits.
You asked the Plan to pre-approve 12 skilled nursing visits and 12 home health aide visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 12 skilled nursing visits and 12 home health aide visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found you do not have documented skilled nursing needs. As such, the requested home health skilled nursing services and associated home health aide services, are not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 12 skilled nursing visits and 12 home health aide visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 skilled nursing visits and 12 home health aide visits.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99215) provided March 3, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you do not wish to be under paid for doctor's visits nor do you wish to receive funds that you are not entitled to receive at the time of service. The Plan denied your request. The Plan says this claim was processed with the correct copayment 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 $65 copayment for out of network mental health services. You have been asked to pay $65 copayment for the office visit. The office visit falls within the Outpatient mental health 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 the outpatient office visit (99215) provided March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on June 18, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this is supported in the records. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 an office visit (99214) provided on June 18, 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 outpatient office visit (99203, 99212) provided June 2, 
2021 to June 16, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that you were told you were covered for 
chiropractic treatment and all you had to pay was your $15 copay. The Plan denied your request. The Plan says 
these services are not covered when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99203, 99212) provided June 2, 2021 to June 16, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic services coded as 77641, 77066 and G0279 
provided September 21, 2020. 
 
You asked the Plan to pay for the diagnostic services. You say that you are appealing because this time the 
insurance company charged you over $400 for the same procedure you have been receiving for at least ten 
years. The Plan denied your request. The Plan says you have not met your deductible for the Plan year 2020. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 deductible which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies.  
 
The item or service you asked the Plan to pay for falls within the benefit category Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is $500 deductible which applies to Outpatient Diagnostic Tests and Therapeutic Services 
and Supplies. This cost sharing is a contractual obligation that had not been met at the time the diagnostic services was received on September 21, 2020. Therefore, we decided that the Plan does not have to pay for the 
diagnostic services coded as 77641, 77066 and G0279 provided September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on April 23, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says there is no evidence of a consultation. 
 
The Plan must follow Medicare rules. Medicare rules say that CPs must document a consultation with a 
primary care or attending physician, or attempt to make one, in the medical record. 
 In this case, there is no evidence that a consultation was attempted or completed. Therefore, we decided that the 
Plan does not have to pay for the psychotherapy services provided on April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
(CPAP) supplies provided February 9, 2021 to May 28, 2021. 
 
You asked the Plan to waive the coinsurance for the CPAP supplies. You say that you never had to pay for 
your CPAP supplies prior to having the Plan and you would like to see if these costs can be waived. The Plan 
denied your request. The Plan says the claim was processed with the correct copayment 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 20% 
coinsurance for the cost of Medicare covered DME and supplies.  
 
You have been asked to pay $106.79 for the CPAP supplies. The CPAP supplies falls within the Durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the continuous positive airway pressure (CPAP) supplies provided February 9, 2021 to May 28, 
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 September 30, 2020. 
 
  You asked the Plan to pay for physical therapy services. You say that plans are required to pay non-contracted 
providers at the preferred provider rate if the services are not available from preferred providers. You say that 
the in-network benefits should be honored, and the claim should be processed for payment. The Plan denied 
your request. The Plan says the code is not appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of 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 September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper and lower denture (D5110, D5120). 
 
You asked the Plan to pre-approve a complete upper and lower denture. You say that your dentures never fit 
you. You went back to the provider for an adjustment and the provider kept pushing teeth into your gums and 
you walked out. You also say that the soft reline was never done and you received a second opinion. The new 
provider advised your previous dentures were done incorrectly. The Plan denied your request. The Plan says 
this service is allowed one time every 60 months. The Plan also says you had this service less than 60 months 
ago. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a complete 
upper and lower denture once every 60 months.  
 
 
 
 We looked at the file and Medicare rules. The records show that you received a complete upper and lower 
denture on April 12, 2021, therefore, you have exhausted your maximum benefit for this service. Based on this 
information, we decided that the Plan's rules for coverage of a complete upper and lower denture have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a complete upper and lower denture 
(D5110, D5120).  
 
Your complaint about the complete upper and lower denture you received April 12, 2021 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for scanning computerized ophthalmic 
diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (91234) 
provided March 16, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic service. You say that you have already paid a 
$40 copay for the eye exam and you should not have to pay an additional copay. You were never told that the 
testing would be billed separately. The Plan denied your request. The Plan says the claim was processed with 
the correct copayment 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 $90 
copayment for each covered diagnostic procedure or test at a network doctor's office.  
 You have been asked to pay $38.64 $90 copayment for the diagnostic service. Since the allowed amount was 
less than the copayment amount, you are responsible for the lesser amount. The diagnostic service 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 scanning computerized ophthalmic diagnostic imaging, posterior segment, with 
interpretation and report, unilateral or bilateral; retina (91234) provided March 16, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing provided on December 2, 2020. 
 
You asked the Plan to pay for lab test. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says that the denial of payment for this testing is correct, because the enrollee did not 
meet the clinical criteria for this HLAB27 typing test. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this 
testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for 
laboratory testing provided on December 2, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) crowns (D2750). 
 
You asked the Plan to pre-approve 6 crowns. You say that the enrollee's front teeth need crowns, and all of the 
posterior teeth need crowns to open the bite. You also say that the services are medically necessary. The Plan 
denied your request. The Plan says these services are 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 Plans coverage rules apply in this case. The Plan covers crowns when 
the services are medically necessary and reasonable.  
 
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 crowns. Our reviewer says that the Plan 
allows for crowns in certain circumstances. The coverage for procedures is limited as well by the procedure 
code listing. Our physician reviewer found the submitted codes are not listed as covered services and there 
would be no necessity for the requested procedures. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of crowns have not been met. Therefore, we decided that the Plan does not have to 
pre-approve six (6) crowns (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist services rendered on June 14, 
2021. 
 
You asked the Plan to waive the copayment for these services. You say that this was a follow-up visit after 
surgery. The Plan denied your request. The Plan says the copayment was applied 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 $35 
copayment for each in-person specialist visit. 
 
Review of the file shows that you had specialist services on June 14, 2021.  You have been asked to pay a $35 
copayment for these services. These services fall within the in-person specialist visit 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.  
 
The file shows that you had a prior surgical procedure on June 11, 2021 billed with code 52005 
(cystourethroscopy, with ureteral catheterization) and 52332 (cystourethroscopy, with insertion of indwelling ureteral stent). These services have a 0-day post-operative period; therefore, post-operative services are not 
included in payment for the surgery. 
 
Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered 
on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and magnetic resonance imaging (MRI) 
provided by an opted-out physician on June 29, 2021. 
 
You asked the Plan to pay for office visit and MRI. You say that you thought you could go anywhere for this 
service and did not understand it would not be covered. The Plan denied your request. The Plan says the denial 
of payment for these services is correct, because this provider has opted out of Medicare and is not eligible for 
payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit and magnetic resonance imaging (MRI) provided by an opted-out physician on June 29, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit the enrollee 
had on May 21, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that this ER visit was needed because of 
an adverse reaction you had to the Moderna Coronavirus vaccine.  You said that everything related to the 
Coronavirus will be paid. The Plan denied your request. The Plan says you were charged this copayment 
correctly.  The Plan says that it only waives copayments for Coronavirus treatment and testing, not for 
reactions to the vaccine. 
 
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 enrollees contract with the Plan clearly says that enrollees 
must pay a $90 copayment for emergency room visits.  
 
The enrollee has been asked to pay a $90 copayment for the ER visit. 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. Please note that the Plan's website explicitly states that the Plan is only waiving cost sharing for the treatment of Coronavirus as well as testing.  There is no 
provision on the website for a waiver of cost sharing as it relates to vaccine reactions. Therefore, we decided 
that the Plan does not have to waive the copayment for the emergency room (ER) visit the enrollee had on May 
21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Sanexas NeoGen-Series therapy with Nutri-
Pharmaceutical injections provided on March 15, 2021. 
 You asked the Plan to pay for the Sanexas NeoGen therapy with Nutri-Pharmaceutical injections. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
denial of Sanexas neoGen-Series Therapy (electrical cell stimulation), vasopneumatic device therapy, and the 
associated codes for the subcutaneous injection of Nutri-Pharmaceutical blend was appropriate given the 
clinical scenario and the guidance presented. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical 
therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private 
practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that 
NP/PA may perform physical therapy services under State law. The rules also say that claims for compounded 
drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Sanexas NeoGen therapy with Nutri-Pharmaceutical injections have not been met. Specifically, 
review of the file and publicly available records, we find that the physical therapy services at issue in this case 
were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Arizona. 
Additionally, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin 
syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. 
As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as 
billed, the drug administration code, 96372, also cannot be paid. Finally, the office visit at issue was billed with 
modifier 25, which is used to report a significant, separately identifiable Evaluation and Management (EM) 
service by the same physician or other qualified health care professional on the same day of a procedure or 
other service. There is no documentation of any significant, separately identifiable evaluation unrelated to the 
treatment provided to the enrollee on this date of service. Therefore, we decided that the Plan does not have to 
pay for the Sanexas NeoGen-Series therapy with Nutri-Pharmaceutical injections provided on March 15, 2021.