Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 17 additional physical therapy visits.
You asked the Plan to pre-approve the additional physical therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says additional physical therapy is 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 the additional physical therapy. 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 based on the medical records provided there is no documentation 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 under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the member'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 physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 17 additional physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services
provided from December 1, 2020, to December 18, 2020.
You asked the Plan to waive the copayment for the SNF services. You say that this should have been covered
in full. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $0 copayment for days 1-20 and a $178 copayment per day for days 21-100 for skilled nursing
facility services.
Records show that the enrollee was in the SNF continuously from October 14, 2020, to December 18, 2020, for
a total of 65 days. According to the contract, the enrollee does not pay a copayment for the first 20 days. That
would cover the dates of October 14, 2020, to November 3, 2020. After November 3, 2020, the enrollee is
responsible for a $178 copayment per day in accordance with her contract. At the current time, the enrollee is
only being assessed a $178 copayment for the bill representing dates of service December 1, 2020, to
December 18, 2020. However, the Plan could assess a $178 copayment per day for December 1, to December
18, 2020, for a total of $3204 (18 days X $178). 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
skilled nursing facility (SNF) services provided from December 1, 2020, to December 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on May 19, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that the insurance company told you the provider is responsible for the bill. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for radiological diagnostic services. You have been asked to pay $76.62, which is less than the $125 copayment for the ultrasound. The ultrasound 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 the ultrasound provided on May 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on March 6, 2021.
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says that the
new documents that were submitted consist of a progress note for a different date of service other than the
billed date of service. Duplicates of records previously reviewed were also submitted.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents
to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the
physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for physical
therapy services provided on March 6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.

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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, you do not qualify for SNF coverage. You do not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. You are ambulating 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies (99072), the IV tubing extension set
(S1015), and the infection control supplies (S8301) provided on April 22, 2021.
You asked the Plan to pay for the equipment and supplies. You say that you would like these services
reconsidered based on the medical documentation. 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.
Providers must report services with the appropriate CPT code.
We looked at the file and Medicare rules. Code 99072 has a status code of "B" under the Medicare Physicians
Fee Schedule Database (MPFSDB) and no separate payment is made as payment is bundled into the payment
for the services to which this code is incident to. Codes S1015 and S8301 have a status code of "I" under the
Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. Medicare
uses other codes for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pay for the additional supplies (99072), the IV tubing extension set (S1015), and the infection control supplies (S8301) provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a proton therapy visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a proton therapy visit to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.

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 proton therapy visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the bone replacement graft for ridge preservation (D7953) provided on June 24, 2021.
You asked the Plan to reimburse you for the dental service. You say that you went in for a planned extraction. You say that you were advised you also needed a bone graft. You say that you feel you were quoted $100 for the extraction and consultation. You also say that you should not be charged any more than the $450 that you have already paid. The Plan denied your request. The Plan says the bone replacement graft is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the bone replacement graft is not among those covered under this benefit. Additionally, the record shows that you were advised of the cost of
this service prior to receiving it. Therefore, we decided that the Plan does not have to reimburse you for the bone replacement graft for ridge preservation (D7953) provided on June 24, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing provided on May 17, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M are non-covered for CXBladder testing. We looked at the file and Medicare rules. The CxBladder testing in this case was billed with code 0012M. This is not a covered code for CxBladder testing. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) and core buildup (D2950) provided on September 29, 2020.
You asked the Plan to pay for a porcelain/ceramic crown and core buildup. You say that the services at issue were not cosmetic but medically necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) and core buildup (D2950) provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a mandibular partial denture (D5226) provided by a
participating provider on June 30, 2021.
You asked the Plan to pay for a mandibular partial denture. You say that you lost your molar, and you could
not eat properly. The Plan denied your request. The Plan says the dental benefit of partial dentures has already
been met and exhausted.
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 mandibular
partial denture once every five years.
We looked at the file and Medicare rules. Evidence was provided which shows a partial denture was provided
on November 7, 2018. Based on this information, we decided that the Plan's rules for coverage of a mandibular
partial denture have not been met. Therefore, we decided that the Plan does not have to pay for a mandibular
partial denture (D5226) provided by a participating provider on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office consultations and treatment to be provided by an
OON provider.
You asked the Plan to pre-approve office consultations and treatment to be provided by an OON provider. You
say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers
that are able to provide these services. Therefore, coverage criteria have not been met.
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
office consultations and treatment to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81542, 88381) rendered by the out-of-network (OON) provider on July 20, 2021.
You asked the Plan to pay for the services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (81542, 88381) rendered by the out-of-network (OON) provider on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing services provided on September
23, 2020.
You asked the Plan to pay for the testing services. You say that the specimen is collected at the physician office
and shipped to the lab for processing. The Plan denied your request. The Plan says there are no modifiers
allowed with this code pair.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. We find that CPT code G0483 was billed with code G0480. When billed with this code pair, code G0480 is not eligible for payment. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing services provided on September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy (D3310) provided on July 9, 2021.
You asked the Plan to pay for endodontic therapy. You say that the provided services were for an emergency. The Plan denied your request. The Plan says the services at issue are not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 endodontic therapy (D3310) provided on July 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services
provided from November 1, 2020, to November 30, 2020.
You asked the Plan to waive the copayment for the SNF services. You say that this should have been covered
in full. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $0 copayment for days 1-20 and a $178 copayment per day for days 21-100 for skilled nursing
facility services.
Records show that the enrollee was in the SNF continuously from October 14, 2020, to December 18, 2020, for
a total of 65 days. According to the contract, the enrollee does not pay a copayment for the first 20 days. That
would cover the dates of October 14, 2020, to November 3, 2020. After November 3, 2020, the enrollee is
responsible for a $178 copayment per day in accordance with her contract. At the current time, the enrollee is
only being assessed a $178 copayment for the bill representing dates of service November 1, 2020, to
November 30, 2020. However, the Plan could assess a $178 copayment per day for November 4, 2020, to
November 30, 2020, for a total of $4628 (26 days X $178). 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 skilled nursing facility (SNF) services provided from November 1, 2020, to November 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311) for a power wheelchair.
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say that the requested wheelchair features are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested wheelchair features 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 an expandable controller with harness and electronic connection. Our reviewer says that the requested wheelchair features are not considered medically reasonable and necessary in this case. Our physician reviewer found that, according to the provided records, the enrollee has 3+/5 bilateral wrist and hand strength with range of motion that is reported to be within functional limits. The enrollee is reported to be independent with oral hygiene and eating, thus indicating that the enrollee's upper extremity strength and function are adequate to control the wheelchair's power options with their own switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller with harness and electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311) for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the heparin flush service you received at an
outpatient hospital facility
You asked the Plan to waive the copayment for the heparin flush service. You say that you have been receiving
these services for years and never paid a copayment for this service. You said that you are on a fixed income
and cannot afford this. 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 $50
copayment for visits to an outpatient hospital.
You have been asked to pay a $50 copayment for the heparin flush service. The heparin flush service falls
within the visits to an outpatient hospital 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 heparin flush service you received at an outpatient hospital facility
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided on December 24, 2020.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you fell over your
dog onto the hardwood floor, hitting your face and your nose was bleeding heavily. You say that your son's
girlfriend called the ambulance against your wishes, and you refused transport to the hospital because of your
concerns of Coronavirus exposure at the hospital. The Plan denied your request. The Plan says the Medicare
ambulance benefit is a transportation benefit and without a transport there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on December 24, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport
(A0998) provided on December 24, 2020.