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

We decided that the Plan does not have to pay for the office visit and related services received on November 17, 2020 and December 15, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit and related services. You say that you were unaware that a referral was needed for these services. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit and related services received on November 17, 2020 and December 15, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit rendered on June 1, 2021.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. 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 $20
copayment for each primary care physician's office visit.
Review of the file shows that you had an office visit on June 1, 2021. You have been asked to pay a $20
copayment for these services. These services fall within the primary care physician's office 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 Plan confirmed that you are not being charged for the removal of impacted cerumen services. The only
amount you are being asked to pay is the $20 copayment for the office visit. Therefore, we decided that the
Plan does not have to waive the copayment for the office visit rendered on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 15, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on January 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screen panel (81238, 81404,
81407, 81408, 81411, 81439) provided on March 3, 2021.
You asked the Plan to pay for a hereditary cardiovascular screen panel. You say that this was billed correctly.
The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients.
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not
covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular
screen panel have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary
cardiovascular screen panel (81238, 81404, 81407, 81408, 81411, 81439) provided on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic images (D0330), periodic oral evaluation (D0120) and prophylaxis (D110), provided on April 15, 2021.
You asked the Plan to pay for the routine dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the 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. 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. Specifically, you received the services from an out-of-network provider and are responsible for the difference between the maximum allowable fee and the providers fee. Therefore, we decided that the Plan does not have to pay for the panoramic images (D0330), periodic oral evaluation (D0120) and prophylaxis (D110), provided on April 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 3 PT home care visits.

You asked the Plan to pre-approve the PT visits. You say that since you have come home from the nursing home and have been receiving PT at home, the physical therapist can see a big improvement. The Plan denied your request. The Plan says based on the progress made and your ability to perform the home exercise plan independently, the skilled PT home care visits are no longer medically necessary.

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 the PT visits. Our reviewer says that ongoing home health PT services are not medically necessary or reasonable. Our physician reviewer found you do not have documented skilled PT needs. Our reviewer also found that you appear to have reached a plateau in function.

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 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the 3 PT home care visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions.
You asked the Plan to pre-approve percutaneous lysis of epidural adhesions. You say that the records provided
support the need for the services requested. The Plan denied your request. The Plan says there is not enough
medical proof that shows the safety and/or success of removing adhesions using solution injection or by a
catheter. The Plan says that this type of surgery is considered experimental and/or unproven.
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 percutaneous lysis of epidural
adhesions. Our reviewer says that percutaneous lysis of epidural adhesions is not considered medically
reasonable and necessary in this case. Our physician reviewer found epidural adhesiolysis, performed by
catheter or endoscopically, as a treatment for back pain is considered experimental, investigational and
unproven.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of percutaneous lysis of epidural adhesions have not been met. Therefore, we
decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF services.
You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says the enrollee
does not require the daily skilled therapy or nursing services required to qualify for a skilled nursing facility
stay. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled
nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for
coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to preapprove
the SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120), prophylaxis (D1110), and 
bitewing x-rays (D0274) provided on March 16, 2021. 
 
You asked the Plan to pay for the dental services. You say that prior to your appointment you called the plan. 
You say that you were advised by a plan representative that the services were covered. You say that that the 
dental department advised the correct codes were used. You also say that the services should be covered. The 
Plan denied your request. The Plan says the services that you received are dental in nature. The Plan also says 
that routine dental services are not covered by the Plan or Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule.  
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the oral evaluation (D0120), 
prophylaxis (D1110), and bitewing x-rays (D0274) provided on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on October 30, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99233 is not supported.

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 99233 is Level 3 subsequent hospital care for evaluation and management of patient, including detailed interval history and medical decision making of moderate complexity, typical time 35 minutes. 

We find that CPT code 99233 is not supported in the medical record. Specifically, there is no documentation of 35 minutes of Level 3 subsequent hospital care spent on the enrollee. Based on this information, we decided

that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered on October 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies, materials, and clinical staff time (99072) provided on April 22, 2021.
You asked the Plan to pay for supplies, materials, and clinical staff time. You say that this is a covered service. The Plan denied your request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that a status code of B in the Medicare Physician Fee Schedule Database (MPFSDB) indicates that payment for covered services is always bundled into payment for other services not specified. We looked at the file and Medicare rules. The code at issue has a status code of B, meaning payment for this service is bundled into payment for other services. Based on this information, we decided that Medicare rules for coverage of supplies, materials, and clinical staff time have not been met. Therefore, we decided that the Plan does not have to pay for supplies, materials, and clinical staff time (99072) provided on April 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation 
(A0429, A0425) provided on January 25, 2021. 
 
You asked the Plan to waive the copayment for emergency ambulance transportation. You say that you were 
not aware there would be a charge for this service. 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $440 copayment for ambulance services.  
 
The enrollee has been asked to pay a $440 copayment for emergency ambulance transportation. The services at 
issue fall within the ambulance services benefit category. 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. Therefore, we decided that the Plan does not have to waive the 
copayment for emergency ambulance transportation (A0429, A0425) provided on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for patient of extreme age, younger than 1 year
and older than 70 (CPT code 99100) provided to the enrollee on October 16, 2020.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says this service is not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the service have not been met. Medicare guidance says that
procedure 99100, which has a status indicator of 'B' on the Centers for Medicare & Medicaid Services (CMS)
Physician Relative Value File, is always bundled into payment for other services not specified and no separate
payment is made per Medicare. Therefore, we decided that the Plan does not have to pay for anesthesia for
patient of extreme age, younger than 1 year and older than 70 (CPT code 99100) provided to the enrollee on
October 16, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT).
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee is a candidate for surgery.
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 therapy. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the radiation treatment itself is not disputed in this case, but rather the need for daily image guidance.
When treating skin cancers, there is generally not a need for IGRT, unless deep structures are being treated.
There is no plausible rationale for why IGRT would be needed 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 therapy have not been met. Therefore, we decided that the Plan does not
have to pre-approve image-guided radiation therapy (IGRT).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health visits you had from April 9, 2021, through May 7, 2021.
You asked the Plan to waive the copayments for the outpatient mental health services. You say that you cannot afford these copayments. You said that had you known that your plan was no longer offering a copayment waiver due to the Coronavirus pandemic, you would not have had the services. The Plan denied your request. The Plan says you were charged these copayments 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 $40 copayment per session for outpatient mental health services. You have been asked to pay a $40 copayment per session for the outpatient mental health services. There is no provision in your 2021 Evidence of Coverage for a waiver of these copayments due to the pandemic. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for outpatient mental health visits you had from April 9, 2021, through May 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from March 4, 2021, to March 19, 2021.
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that your stay at the rehabilitation facility should not be coded as a hospital stay. The Plan denied your request. The Plan says the copayment for the inpatient stay 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 $390 copayment each day for days 1 to 5 for Medicare-covered hospital care.
You have been asked to pay a total of $1,950 ($390 copayment x 5 days = $1,950) for the inpatient hospital stay. Inpatient rehabilitation services fall within the Inpatient hospital 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 reduce the copayment for the inpatient hospital stay provided from March 4, 2021, to March 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Arformoterol.
You asked the Plan to pre-approve Arformoterol. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Arformoterol. Our reviewer says that
the documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found the enrollee has a past medical history of chronic obstructive pulmonary disease and asthma.
Based on the medical records provided and the Medicare-approved major drug compendia, there is no
documentation that the Arformoterol is medically reasonable and necessary for the enrollee as records indicate
it will be used in combination with another long acting beta-adrenergic agonist (which is not recommended).
Therefore, the enrollee does not meet criteria for the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Arformoterol have not been met. Therefore, we decided that the Plan does not
have to pre-approve Arformoterol.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint.
You asked the Plan to pre-approve radiofrequency ablation of the sacroiliac joint. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 radiofrequency ablation of the sacroiliac joint. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/investigational because of the wide variation in efficacy. 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 radiofrequency ablation of the sacroiliac joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam of one surface (D2140) and amalgam of three surfaces (D2160) provided on April 5, 2021.

You asked the Plan to pay for the amalgams. You say that you feel that this bill is too high for you to be in charge of. The Plan denied your request. The Plan says these services are not covered.

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. Your dental rider only provides coverage for preventive services.

Amalgams are not a preventive service. Therefore, we decided that the Plan does not have to pay for the amalgam of one surface (D2140) and amalgam of three surfaces (D2160) provided on April 5, 2021.