Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on July 8, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 out of network physician services provided to the enrollee on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete upper denture (D5110) and a partial lower denture (D5214) provided on October 5, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for a complete upper denture and a partial lower denture. You say that you spoke with someone a few weeks ago and they mentioned that you had a credit of $890 that would pay the rest of your bill. The Plan denied your request. The Plan says the services at issue are not covered under your contract under any normal circumstance.

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 a complete upper denture (D5110) and a partial lower denture (D5214) provided on October 5, 2020, by an out-of-network (OON) provider.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 the medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. 

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. Specifically, medically necessary services are being obtained at the enrollee's current level of care.

This means admission into a LTACH is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgery services provided on February 16, 
2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
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 75774 is angiography, selective, each additional vessel 
studied after basic examination, radiological supervision and interpretation (List separately in addition to code 
for primary procedure). We find that CPT code 75774 is not supported in the medical record. Specifically open 
and percutaneous interventional vascular procedures include operative angiograms and/or venograms which 
shall not be separately reported as diagnostic angiograms/venograms. The medical records provided do not 
show that the service billed were a distinct procedural service. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met.  
 
The CPT Code Manual definition of code 99153 is Moderate sedation services provided by the same physician 
or other qualified health care professional performing the diagnostic or therapeutic service that the sedation 
supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's 
level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in 
addition to code for primary service).  We find that CPT code 99153 is a technical component only code and 
does not have a related professional code. Based on this information, we decided that the Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient surgery 
services provided on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on March 17, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you were charged a $45 copayment. 
The Plan denied your request. The Plan says the copayment 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 $45 
copayment for each Medicare-covered visit from a network provider. Covered services include outpatient 
physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for 
age-related macular degeneration.  

You have been asked to pay a $45 copayment for the eye exam. The eye exam falls within the "Vision care" 
benefit category. The records show a medical eye exam was billed. 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 eye exam provided on March 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
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 you were admitted after a fall in skilled nursing and was treated for a metatarsal 
fracture. You had recent lumbar spine surgery. Medical problems are stable. 

There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
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. In conclusion, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the WATS 3D biopsy services provided on March 19, 2021. 
 
You asked the Plan to pay for the services provided. You say that WATS is indicated in addition to routine 
endoscopy in those with known or suspected Barrett's Esophagus. The Plan denied your request. The Plan says 
medical literature does not support the clinical utility of the testing. 

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services provided. Our physician 
reviewer found that the enrollee's available record notes multiple endoscopic procedures over many years that 
have not supported the high likelihood of Barrett's Esophagus. Neither routine histologic inspection, nor 
documentation of endoscopic appearance, newly support interval development of Barrett's changes. Findings 
were limited to a benign distal esophageal stricture, superficial gastric ulcer, and mild esophageal erythema. 
There was no documentation of Z-line irregularity, nor of tongues of salmon-colored tissue. Therefore, the 
enrollee's scenario does not meet the spirit of guidance relative to the medically necessary use of WATS-3D 
biopsy 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 services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the WATS 3D biopsy services provided on March 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210) provided on August 3, 2021.

You asked the Plan to pay for the dental service. You say that you felt the extraction was urgently needed. You say that you had an infection. You say that you could not wait to see your endodontist later in the month. You also say that the service should be covered. The Plan denied your request. The Plan says the extraction 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the extraction is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction (D7210) provided on August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant removal (D6100) provided on December 9, 2020.

You asked the Plan to pay for the implant removal. You say that a screw that you had placed many years ago
had worked its way out. You say that no one told you that this service would not be covered. You also say that
you are on a low, fixed income and cannot afford this bill. The Plan denied your request. The Plan says implant
removal is not listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the implant removal is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the implant
removal (D6100) provided on December 9, 2020.
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 need IRF care. The Plan denied your request.
The Plan says rules for IRF care have not been met.

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 you were admitted for non-surgical management of a shoulder fracture after a
fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. 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. In conclusion,
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted ambulance service (A0999) provided on May 11, 
2021. 
 
You asked the Plan to pay for the transportation service. You say that you were advised by a home aide that the 
enrollee may have had a seizure. You say that you were advised by the head nurse to call an ambulance. You 
say that the enrollee was evaluated. You say that you were advised you could either take the enrollee to the 
hospital or monitor the enrollee at home. You also say that you feel this was a justified concern. The Plan 
denied your request. The Plan says there was no transport provided. The Plan also says there is no payable 
service since no transport was provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. 

The ambulance company did not provide transport services on May 11, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the unlisted ambulance service (A0999) provided 
on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit on April 13, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the service should be 
covered because you cannot afford the bill. The Plan denied your request. The Plan says you have been asked 
to pay 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 $35 
copayment for each Medicare-covered specialist office visit.  
 
You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit 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 the specialist office visit on April 13, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the medical eye exam provided on June 28, 2021.

You asked the Plan to waive the copayment for the medical eye exam. You say that this was a routine eye exam and should have a $0 copayment. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.

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. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There were no medical records or claim form with the diagnosis codes submitted to support that a medical eye exam was performed. Therefore, we decided that the Plan has to waive the copayment for the medical eye exam provided on June 28, 2021.

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: 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 October 28, 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 October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the basivertebral nerve.
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried and failed conservative treatment without relief. The Plan denied your request. The Plan says unproven procedures are not covered by Medicare.
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 requested services. Our physician reviewer found that the enrollee has chronic low back pain. She has had epidural steroid injections, radiofrequency ablation of the medial branches, and a home exercise program. Her magnetic resonance imaging (MRI) shows multi-level degenerative disc disease, facet arthropathy and Modic Type II changes at L5-S1. The request is for radiofrequency ablation of the basivertebral nerve at those two levels. This procedure is still considered experimental/ investigational as the studies published to date do not demonstrate a sustained improvement in pain. Therefore, the request is deemed not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the basivertebral nerve.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on June
30, 2021.

You asked the Plan to pay for a comprehensive oral evaluation. You say that you were not aware that the
treatment provided to you would include the service along with the tooth extraction that you needed. The Plan
denied your request. The Plan says you have exhausted your allowed 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. The Plan covers a
comprehensive oral evaluation once every 6 months.

We looked at the file and Medicare rules. The records show that you received a comprehensive oral evaluation
on March 8, 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 comprehensive oral evaluation have not been
met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150)
provided on June 30, 2021.