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 June 16, 2021.  You asked the Plan to pay for this service.. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have 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 must 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 June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit (99203) provided on July 13, 2021.  You asked the Plan to waive the copayment for office visit. You say that the services should be covered as it was a routine exam. The Plan denied your request. The Plan says the cost sharing applied correctly based on the services rendered.  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 $15 copayment for Physician/Practitioner services, including doctor's office visits, specifically for each Medicare-covered specialist visit.       You have been asked to pay a $15 copayment for a specialist office visit. The plan has reduced the copayment from $20 to $15. The record indicates that the provider is a specialist. 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 an office visit (99203) provided on July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a GeneSight Psychotropic assay rendered on June 7, 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 services were not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that pharmacogenetic testing 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee is documented has having a diagnosis of major depressive disorder documented in the medical necessity form. The documentation contains results of the testing with no additional clinical documentation. The documentation does not support that the testing was reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for a GeneSight Psychotropic assay rendered on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for individual psychotherapy services (90832) provided on June 10, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the psychotherapy services. You say that you are requesting review of the documents and processing of the claim for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 individual psychotherapy services (90832) provided on June 10, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the robotic surgical services rendered on January 22, 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 services are not covered.  The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.  We looked at the file and Medicare rules. Billed procedure code S2900 (surgical techniques requiring use of robotic surgical system [list separately in addition to code for primary procedure]) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the robotic surgical services rendered on January 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the outpatient surgery you had from April 15, 2021, to April 16, 2021.  You asked the Plan to waive the coinsurance for the outpatient surgery. You say that you do not believe you should owe this much. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  The Plan says that you are not a Qualified Medicaid Beneficiary (QMB), so you are responsible for this cost sharing.  Instead, your Medicaid plan pays your Part B premiums only because you do not have full Medicaid benefits.  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 outpatient surgery.   You have been asked to pay 20% coinsurance for the outpatient surgery. 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 outpatient surgery you had from April 15, 2021, to April 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing services provided from March 14, 2021, to April 12, 2021.  You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.   The file shows that the enrollee received 100 days of SNF care during the benefit period from November 12, 2020, to March 13, 2021. The Plan has covered 100 days of SNF care.   Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from March 14, 2021, to April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a lower partial denture (D5212).  You asked the Plan to pre-approve a lower partial denture. You say that the partial denture the enrollee currently has was completed at a different provider's office and the enrollee states they do not fit properly. You also say that the enrollee is in pain and has discomfort. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.  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 lower partial denture once every five plan years.   We looked at the file and Medicare rules. The records show that you had a lower partial denture provided to you on December 12, 2019, 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 lower partial denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5212).
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 15, 2021.  You asked the Plan to pay for this service. 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 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth (excluding final restoration) (D3310) and crown - porcelain/ceramic (D2740) for tooth 22.  You asked the Plan to pre-approve a root canal and crown. You say that you are in pain and the services are medically necessary. The Plan denied your request. The Plan says you have exhausted your benefits 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 a root canal and crown when the services are medically necessary and reasonable.   We looked at file and Medicare rules. The Plan provided a documentation that a root canal and crown were previously covered on May 18, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of a root canal and crown has been exceeded. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth (excluding final restoration) (D3310) and crown - porcelain/ceramic (D2740) for tooth 22.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pest control provided on May 24, 2021.

You asked the Plan to pay for the pest control. You say that the service should be covered. The Plan denied
your request. The Plan says you did not contact the health plan to select the Pest Control benefit until May 27,
2021, and you were not approved for the benefit until June 2, 2021.

The Plan must follow Medicare rules. Medicare rules say that MA plans may choose to offer some benefits to
enrollees in addition to the covered Medicare Part A and Part B (and Part D, as applicable) benefits.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the pest control have not been met. Specifically, you did not receive prior authorization for the
service obtained. This means the service is not covered. Therefore, we decided that the Plan does not have to
pay for the pest control provided on May 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the occupational therapy evaluation provided by an occupational therapist on January 5, 2021 and the physical therapy evaluation provided by a physical therapist on January 22, 2021.   You asked the Plan to pay for the occupational and physical therapy evaluation. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers 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 code billed.  The Plan must follow Medicare rules. Medicare rules say that services of an occupational or 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 the occupational and physical therapy evaluation have not been met. Specifically, the billing provider is a non-physician practitioner. As such, occupational and physical therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the occupational therapy evaluation provided by an occupational therapist on January 5, 2021 and the physical therapy evaluation provided by a physical therapist on January 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest you had on August 1, 2020.  You asked the Plan to waive the copayment for the CT scan. You say that you do not think you should have to pay this copayment.  You stated that you paid your emergency room copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $225 copayment for advanced imaging services.   Your contract says that if advanced imaging services are received as part of an emergency department evaluation, then you will only pay the advanced imaging copayment, not the emergency room copayment. You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the advanced imaging 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 computed tomography (CT) scan of the chest you had on August 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the custom foot orthotics (CPT code L3000 X 2).  You asked the Plan to pre-approve foot orthotics. You say that you have foot deformity and need custom foot orthotics to prevent you from falling. The Plan denied your request. The Plan says this item is not a covered benefit. The Plan states the inserts and other shoe modifications are a covered benefit if they are on a shoe that is an integral part of a covered brace. The Plan states the clinical documents do not show this information and criteria is met.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve the custom foot orthotics (CPT code L3000 X 2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation admission and services provided from May 18, 2021, to June 1, 2021.  You asked the Plan to waive the copayment for the inpatient rehab care. You say that you have never had to pay a copayment for care before and you do not understand why you are responsible for this cost now. You were not advised you would have a copayment for these services. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. Inpatient rehabilitation facilities are not the same as skilled nursing facilities. 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 $225 for each of the first five days of inpatient hospital care. There is a $0 copay for each additional day. Inpatient hospital care includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient services.  You have been asked to pay a $1,125 for the inpatient rehabilitation admission that exceeded five days ($225 x 5 days = $1,125). Inpatient rehabilitation care falls 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 waive the copayment for the inpatient rehabilitation admission and services provided from May 18, 2021, to June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and additional intraoral periapical x-ray (D0230) provided on July 6, 2020 by an out-of-network (OON) provider.  You asked the Plan to pay for the problem focused limited oral evaluation and additional intraoral periapical x-ray. You say that this is a medical claim, not a dental claim. The Plan denied your request. The Plan says the problem focused limited oral evaluation is not a covered service. The Plan also says that your intraoral x-rays benefit has been satisfied and the frequency limitation has been exceeded. The Plan also says that the treating provider is OON, the coinsurance level will apply to the average negotiated in-network fee schedule (INFS) in your area, and you are responsible for the difference between the INFS and dentists' charged fees.  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, problem focused limited oral evaluation (D0140) is not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure code per calendar year, and you are responsible for a 50% coinsurance when the service is received out-of-network. The record shows that you received a first intraoral periapical x-ray on July 6, 2020 which was covered by the Plan at the 50% coinsurance, and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and additional intraoral periapical x-ray (D0230) provided on July 6, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 0242U provided on April 23, 2021.  You asked the Plan to pay for the targeted genomic sequence analysis panel. 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 supported by the 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 0242U is targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements.  We find that CPT code 0242U is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the targeted genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 0242U provided on April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay more for the endodontic therapy provided on August 4, 2021.  You asked the Plan to pay more for the endodontic therapy. You say that you know the treating provider was out-of-network, and you received approval to be treated by them. You also say that you thought you would only be responsible for half of the entire bill. The Plan denied your request. The Plan says that this claim processed appropriately, applying the correct member responsibility.  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.  We looked at the file and Medicare rules. The contract says that the Plan offers a maximum $2,500 allowance with 50% coinsurance every year for supplemental comprehensive dental services, including endodontic services. The record shows that you received approval from the Plan to be treated by this out-of-network provider. Nothing was provided to you stating you would owe more than the 50% coinsurance for this service being rendered by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the endodontic therapy have been met. Therefore, we decided that the Plan has to pay 50% of the charge for the endodontic therapy provided on August 4, 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.