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

We decided that the Plan does not have to provide coverage for additional routine transportation trips (A0120).
You asked the Plan to provide coverage for additional routine transportation trips. You say that the enrollee suffers from many serious health complications and the enrollee visits many different specialists. You say that the enrollee would benefit from having the additional transportation. The Plan denied your request. The Plan says the enrollee has exhausted the maximum benefit of 60 one-way trips per year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips (A0120).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an OT on December 20, 2019.

You asked the Plan to pay for occupational therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers. 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 a physical 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 occupational therapy services have not been met. Specifically, the billing provider is a nurse practitioner. As such, OT 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 OT on December 20, 2019.
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) mask (A7034), filter (A7038), and tubing (A7037), provided on April 26, 2021.
You asked the Plan to waive the coinsurance for the CPAP supplies. You say that the items should be covered. The Plan denied your request. The Plan says the cost share 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 10% coinsurance for Durable medical equipment (DME) and related supplies. You have been asked to pay a 10% coinsurance for the CPAP supplies. These supplies fall 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) mask (A7034), filter (A7038), and tubing (A7037), provided on April 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on March 17, 2021, to March 30, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you believe this copayment should be waived just like the copayment that was waived for your inpatient stay on 1/27/2021. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $200 copayment per day, for days 1 to 5 and a $0 copayment per day, after day 5, for inpatient hospital care. You have been asked to pay a $200 copayment for inpatient hospital care. The records show that you were inpatient for 13 days. The EOC confirms that $200 per day, for the first 5 days, is the required copayment for this service ($200 x 5 days = $1,000). The records also show that the Plan waived copayments for Coronavirus related claims which ended on January 31, 2021. Therefore, inpatient hospital care after January 31, 2021 do not apply. 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 inpatient hospital care provided on March 17, 2021, to March 30, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystoscopy (55214), provided on February 2, 2021.
You asked the Plan to waive the copayment for the cystoscopy. You say that you can not afford the copayment and would like it lowered. The Plan denied your request. The Plan says the cost share 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 $400 copayment for same-day outpatient surgery in an Outpatient Hospital Facility. for outpatient hospital services. You have been asked to pay a $400 copayment for same-day outpatient surgery in an Outpatient Hospital Facility. for the cystoscopy. the cystoscopy falls within the outpatient hospital services 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 cystoscopy (55214), provided on February 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for magnetic resonance imaging (MRI).
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the requested provider is out-of-network.
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 a referral out-of-network for magnetic resonance imaging (MRI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three precision attachments (D5862 x3) provided on March 15, 2021.

You asked the Plan to pay for the precision attachments. You say that you believe these services should be covered because it was all part of the denture. The Plan denied your request. The Plan says this service is not a covered benefit 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 precision attachments (D5862 x3) provided on March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7140 x 4), limited oral evaluation (D0140),
comprehensive periodontal exam (D0180) provided from March 30, 2021, to May 20, 2021.
You asked the Plan to pay for the dental services. You say that you were in a lot of pain. You say that you had
to get the procedures done. You also say that the extractions are a vital part of your healthcare and should be
covered. The Plan denied your request. The Plan says extractions are not listed as covered services. The Plan
says that comprehensive periodontal exam is not listed as a covered service either. The Plan says that 1 limited
oral evaluation is covered per year. The Plan also says that 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, the extractions and comprehensive
periodontal exam are not among those covered under this benefit. The record shows that the Plan paid for a
limited oral evaluation that you received on March 30, 2021. Therefore, we decided that the Plan does not have
to pay for the extractions (D7140 x 4), limited oral evaluation (D0140), comprehensive periodontal exam
(D0180) provided from March 30, 2021, to May 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure device (CPAP).
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation demonstrating that the device has irreparable damage, has been lost, is not working, or is malfunctioning.
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 device. Our reviewer says that a replacement continuous positive airway pressure device (CPAP) device is not medically necessary. Our physician reviewer found the manufacturer has issued a voluntary recall for some devices and has announced a plan to either replace parts or replace devices that are involved. There is no documentation that your CPAP is non-functional, and it is within the 5-year expected life of the device. The device will be repaired or replaced at the expense of the manufacturer if needed. It is not medically necessary for the insurer to cover the cost of a replacement device in this circumstance. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure device (CPAP).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional outpatient speech therapy visits.

You asked the Plan to pre-approve the additional visits. You say that you request for approval of the speech therapy treatments for the enrollee to continue to progress in her ability to communicate. The Plan denied your request. The Plan says the request for 5 outpatient speech therapy visits is not reasonable and necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy of 12 outpatient visits and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee was educated on communication strategies, word finding strategies. The enrollee is at 80-90% of reaching her short-term goals. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional outpatient speech therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Actemra ACTPen.

You asked the Plan to pre-approve an Actemra ACTPen. You say that this is required to treat the enrollee's condition. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

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 an Actemra ACTPen.

Benefits for an Actemra ACTPen 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation on x-ray examination made elsewhere, written report coded 76140 provided on May 30, 2021.
You asked the Plan to pay for the consultation on x-ray examination made elsewhere, written report. 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 payable.
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 76140 is the consultation on x-ray examination made elsewhere, written report.
We find that CPT code 76140 is not supported in the medical record. Specifically, this code has a status code of "I." A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the consultation on x-ray examination made elsewhere, written report have not been met. Therefore, we decided that the Plan does not have to pay for the consultation on x-ray examination made elsewhere, written report coded 76140 provided on May 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3330).
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit more than once per year.
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 root canals (a type of endodontic therapy) once per year.
The file shows that a root canal was previously approved for one root canal for tooth #3 on October 14, 2021. The benefits for this type of service have been exhausted. Based on this information, we decided that the Plan's rules for coverage of the therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy (D3330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on April 27, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that no one took the time to explain to you how this dental plan is set up. You also say that you are on a set income. The Plan denied your request. The Plan says benefits for these services have been satisfied and the frequency limitations have been exceeded. The Plan also says that you were mailed copies of your dental plan showing specific coding and what limitations apply to those codes.
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, periodontal exam and comprehensive oral evaluation are limited to one procedure code every three years, and full mouth or panoramic x-rays are limited to one procedure code every five years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on September 24, 2019, and your periodontal exam and comprehensive oral evaluation, and full mouth or panoramic x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on April 19, 2021.
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 is not documented.
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 99213 is office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family. We find that CPT code 99213 is not supported in the medical record. Specifically, the submitted records do not included documentation of an office visit on the billed date of service. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on April 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for insertion of a gastrointestinal tube (44500) and unlisted nasal surgery procedure (30999) provided on April 24, 2021.
You asked the Plan to pay for 44500 and 30999. You say that you feel that this is a very important procedure. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these procedures were not done according to the clinical 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 44500 is introduction of long gastrointestinal tube. The CPT Code Manual definition of code 30999 is unlisted nasal surgery procedure.
We asked our coder 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 44500 and 30999. Our reviewer says that these codes do not meet the Medicare criteria for payment. Our reviewer found the documentation states that "the Corpak feeding tube tip is at the gastric antrum approaching the pylorus." Code 44500 is used for oral introduction of a long drainage tube into the small bowel. The documentation does not show that the tube was placed into the small intestine; therefore, code 44500 cannot be confirmed. Code 30999 would be included in the primary code for this procedure and should not be reported separately. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 44500 and 30999 have not been met. Therefore, we decided that the Plan does not have to pay for insertion of a gastrointestinal tube (44500) and unlisted nasal surgery procedure (30999) provided on April 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy visits. You say that adjustments are allowed to
meet your needs. You say that emergency room visits will replace physical therapy visits which will cost more.
The Plan denied your request. The Plan says additional visits are not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 additional physical therapy visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found that you had prior therapy and have been instructed in
a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to
safely and effectively provide ongoing treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve additional physical therapy visits.