Persius/hicric huggingface dataset:
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 March 12, 2021. 

You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate when 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 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 the 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 March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and intraoral - periapical 
first radiographic image (D0220) provided by a participating provider July 8, 2021. 
 
You asked the Plan to pay for a limited oral evaluation and intraoral - periapical first radiographic image. You 
say that you were not advised that you would have an x-ray done. You say that you do not feel like you should 
have to pay for this. The Plan denied your request. The Plan says you have already exhausted your benefit limit 
for these services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one limited 
oral evaluation every six months, and one intraoral - periapical first radiographic image per year. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a limited oral evaluation and intraoral - periapical first radiographic image were exhausted on June 
25, 2021. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and 
intraoral - periapical first radiographic image (D0220) provided by a participating provider July 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services.
You asked the Plan to waive the copayment for the ambulance services. You say that you were admitted to the hospital and you should not have to pay $200. The Plan denied your request. The Plan says you were charged this cost sharing 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 $200 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $200 for these 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 the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99232) provided on March 4, 2021. 
 
You asked the Plan to pay for hospital care. You say that this is supported in the records. The Plan denied your 
request. The Plan says this is not separately 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, we have confirmed that code 99232 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for hospital care (99232) provided on March 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an osteogenesis stimulator (E0748) provided on February 26, 2021.
You asked the Plan to waive the coinsurance for an osteogenesis stimulator. You say that when you picked up the equipment you were advised that you would not have to pay anything. The Plan denied your request. The Plan says the correct coinsurance was applied.
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 Medicare-covered durable medical equipment and related supplies. You have been asked to pay $905.81, or 20% of the Medicare-allowed charge of $4,529.04, for an osteogenesis stimulator. An osteogenesis stimulator 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 an osteogenesis stimulator (E0748) provided on February 26, 2021.
Your complaint about receiving erroneous or incomplete information from the supplier about your cost-sharing responsibilities 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: 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 October 1, 2020.
You asked the Plan to pay for the physical therapy services. You say that the medical records required to reprocess the denied claim are attached. 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 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 the 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 October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), periodic oral evaluation (D0120) and prophylaxis (D1110) provided on June 10, 2021.
You asked the Plan to pay for the dental services. You say that the dental office advised they were in network with your insurance. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that there is no coverage for periodic oral evaluation when billed on the same day as a comprehensive oral evaluation. The Plan also says that out of network dentists may bill you for any amount greater than what the Plan paid.
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 and the services are listed as covered, there is a 50% coinsurance for the services when received out of network. There is a 50% coinsurance for these services received out of network. Additionally, out of network providers may bill you for any amount greater that what the Plan pays. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), periodic oral evaluation (D0120) and prophylaxis (D1110) provided on June 10, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90834) provided 
April 13, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that this appeal should be granted because 
the services provided were medically necessary and meet all applicable professionally recognized standards of 
healthcare. The Plan denied your request. The Plan says there was no documented contact with the 
attending/primary care physician and there is no referring physician listed on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. The submitted claim does not include a referring provider for the 
services at issue. Based on this information, we decided that Medicare rules for coverage of the psychotherapy 
services have not been met. Therefore, we decided that the Plan does not have to pay for the individual 
psychotherapy services (90834) provided April 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on May 14, 2021.
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you feel that the mammogram should be considered preventative. 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 $0 copayment for diagnostic procedures and tests provided in a primary care provider's office and an $80 copayment for all other locations. The medical records show that you received a diagnostic mammogram on May 14, 2021, at an outpatient hospital facility. Therefore, you are responsible to pay the $80 copayment.
You have been asked to pay an $80 copayment for a diagnostic mammogram. A diagnostic mammogram 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 a diagnostic mammogram provided on May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6740 for tooth #2 and #4, D6245 for tooth #3, D4321, D2950 for tooth #30, D2740 for tooth #30).
You asked the Plan to pre-approve the services. You say that this is not replacing a missing tooth, it's replacement of an existing bridge with recurrent decay and infection. The Plan denied your request. The Plan says tooth #30 has poor prognosis.
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 dental services 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 the various dental services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request is for a crown and buildup for tooth #30, and a bridge replacement for #2-4. Tooth #30 has an existing large two surface restoration. There was no provided information as to why a full coverage crown was needed to restore this tooth. Tooth #30 has loss of bone between the roots, which leaves a furcation involvement which decreases the longevity of the tooth due to a poorer long term prognosis. Crowns are usually considered where there is extensive loss of structure and a conventional restoration would not be sufficient to restore the tooth. In this instance there appears to be two or possibly three surfaces involved, and no cusps affected. Further, where there is a loss of bone between the roots of a molar, the prognosis of the tooth becomes much poorer and crown restorations are usually not considered for these situations. There would be no medical necessity for a crown on #30. Additionally, the upper arch reveals tooth #4 which apparently requires root canal therapy. There is an existing bridge from #2-4 that is being requested to be replaced. There is no clear damage to the bridge that would require replacement, and no provided documentation to indicate why the root canal treatment could not be performed through the bridge and then patched at the access which is commonly done. The Plan does not provide coverage for posterior bridges however, and such a request would not fall under the Plan provisions. As there is no clear reason to replace the bridge, and it involves posterior teeth which are not covered under the Plan provisions, there is no necessity for the requested bridge. 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve dental services (D6740 for tooth #2 and #4, D6245 for tooth #3, D4321, D2950 for tooth #30, D2740 for tooth #30).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (70450) provided to the enrollee on April 2, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the appropriate modifier was not billed in this case.
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 70450 is "Computed tomography, head or brain; without contrast material." We find that CPT code 70450 is not supported in the medical record. Specifically, this code cannot be paid separately from CPT 70496 without the appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (70450) provided to the enrollee on April 2, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a referral to tertiary-level ophthalmology.
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 that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the tertiary level of care is medically necessary. Our physician reviewer found the records show that you have a history of retinal detachment and include letters of medical necessity from an ophthalmologist. The plan's denial is based on an assessment of glaucoma, which is not supported by the totality of the file as the reason for the referral. The records support that the tertiary level of care is reasonable and medically necessary at this time. 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 been met. Therefore, we decided that the Plan has to pre-approve a referral to tertiary-level ophthalmology.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network 
(OON) provider on May 11, 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 (99203) rendered by the out-of-network (OON) provider on May 11, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services represented by codes 99140 and 99100 provided on October 24, 2020.
You asked the Plan to pay for codes 99140 and 99100. 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 providers must report services correctly. We looked at the file and Medicare rules. Codes 99140 and 99100 have a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for these codes under the fee schedule as payment is bundled into the payment for the services to which these codes are incident to. Therefore, we decided that the Plan does not have to pay for the anesthesia services represented by codes 99140 and 99100 provided on October 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion or replacement of a peripheral or gastric 
neurostimulator pulse generator. 
 
You asked the Plan to pre-approve insertion or replacement of a peripheral or gastric neurostimulator pulse 
generator. 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 follows Medicare rules. Medicare rules say that sacral nerve stimulation for urinary incontinence 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 insertion or replacement of a peripheral 
or gastric neurostimulator pulse generator. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the review indicates that upon testing the device has no issues or problems. There is 
no documentation of medical necessity for the requested replacement of the current sacral nerve stimulator. 
The review has determined that the enrollee does not meet the coverage criteria detailed in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion or replacement of a peripheral or gastric neurostimulator pulse 
generator have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion or 
replacement of a peripheral or gastric neurostimulator pulse generator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for treatment with chemotherapy drugs 
(J9022, Q5107) provided on June 28, 2021. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs. You say that you are not able to afford 
the coinsurance at issue and were told by the provider the treatment was covered. The Plan denied your request. 
The Plan says the correct coinsurance was applied. 
 
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 Medicare-covered Part B prescription drugs, including chemotherapy drugs.  
 
You have been asked to pay $2,530.00, or less than 20% of the Medicare-allowed charge of $15.725.52, for 
chemotherapy drugs. Chemotherapy drugs fall within the "Medicare Part B prescription drugs" benefit 
category. This means that you have been asked to pay less than or equal to 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 treatment with 
chemotherapy drugs (J9022, Q5107) provided on June 28, 2021.  
 
Your complaint about receiving erroneous or incomplete information from the provider about your coverage 
and your cost-sharing responsibilities 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.