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

We decided that the Plan does not have to pay for the outpatient hospital services rendered by the out-of-network (OON) provider on February 1, 2021.
You asked the Plan to pay for these 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 outpatient hospital services rendered by the out-of-network (OON) provider on February 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment.
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided you do not meet the criteria for continued acute inpatient mental health treatment for
the dates in question of January 10, 2022 forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. You were not showing any aggressive behaviors, or any treatment required for acute threats of safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodontal scaling and root planing for all four quadrants.
You asked the Plan to pre-approve the periodontal scaling and root planing. You say that your dentist found your teeth to be in bad shape and a deep cleaning is necessary. The Plan denied your request. The Plan says your tooth must have noticeable bone loss or show on an x-ray that there is a hard substance built up on the root of the tooth. The Plan also says that your x-rays do not show that you have these issues.
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 the periodontal scaling and root planing 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 periodontal scaling and root planing. Our reviewer says that the documentation is not sufficient to support the requested periodontal cleaning.
Our physician reviewer found in order to approve this service, the Plan requires periodontal charting showing multiple sites of abnormal pocket depths along with a showing of bone loss or tartar on root surfaces. In this case, the supplied radiographs do indicate bone loss in the posterior regions; however, there is no periodontal charting supplied in the record. If there is periodontal charting is made available along with the full series of x-rays there may be consideration for scaling under code D4341 in some quadrants. Without all required documentation there can be no finding of necessity as the criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does not have to pre-approve the periodontal scaling and root planing for all four quadrants.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a duplex scan provided to the enrollee on February 15, 2021.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says that a corrected claim with an appropriate primary diagnosis code needs to be resubmitted.
The Plan must follow Medicare rules. Medicare rules say that duplex scans are covered for specific indications. 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 the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found in addition to dizziness and giddiness, F42 codes for such as loss of equilibrium - a symptom that is often associated with vertebral basilar disease as may occur with suspected subclavian steal syndrome. This qualifies for coverage of a carotid duplex, as a listed indication is "evaluation of suspected subclavian steal syndrome." We looked at this physician's review, the file, and Medicare rules. The Local Coverage Article cited by the plan in their denial has a list of diagnosis codes that supported medical necessity for duplex scans. However, it is not stated that these diagnosis codes are the only codes that support medical necessity for a duplex scan. The billed diagnosis - R42 - is not listed as excluded anywhere in the guidelines. Our doctor found that the billed diagnosis is appropriate for the denied scan.
Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for a duplex scan provided to the enrollee on February 15, 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
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient (92014) provided July 26, 2021.
You asked the Plan to waive the copayment for the medical eye exam. You say that you would like this claim covered by your vision benefit with a $0 copayment. The Plan denied your request. The Plan says the copayment has been 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 $45 copayment for each Medicare-covered visit with a specialist.
You have been asked to pay a $45 copayment for the medical eye exam. The medical eye exam falls within the Physician/Practitioner services, including doctor's office visits 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 ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient (92014) provided July 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for Transcutaneous Electrical Nerve Stimulation (TENS), vasopneumatic device and Prolotherapy provided on July 20, 2021.
You asked the Plan to pay for TENS, vasopneumatic device and Prolotherapy. The Plan denied your request. The Plan says Medicare does not cover Prolotherapy. Prolotherapy is believed to stimulate the body's ability to heal itself by injecting a natural substance that acts as an irritant and stimulates regenerative processes. Its billing under the trigger point injection code is a misrepresentation of the actual service rendered, which is like acupuncture. The Transcutaneous Electrical Nerve Stimulation (TENS) device, including supplies, for neuromuscular reconditioning is not a Medicare covered benefit. Pneumatic/vasopneumatic devices can be covered only for the treatment of chronic venous insufficiency with venous stasis ulcers, and refractory lymphedema.
The Plan must follow Medicare rules. Medicare rules say that that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. The rules say that beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot. Therefore, we decided that the Plan does not have to pay for TENS, vasopneumatic device and Prolotherapy provided on
July 20, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nail debridement (11720) provided on August 18, 2021. You asked the Plan to waive the copayment for the nail debridement. You say that you thought the services would be covered 4 times a year. The Plan denied your request. The Plan says the cost-sharing 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 $35 copayment for Podiatry services.
You have been asked to pay a $35 copayment for nail debridement. Nail debridement's fall within the Podiatry 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 nail debridement (11720) provided on August 18, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim crown (D2799) provided on August 12, 2021.
You asked the Plan to pay for the dental service. You say that you were advised by the plan representative that the service would be covered at 50%. You also say that the provider did not mention that the service was not covered. The Plan denied your request. The Plan says interim crown 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 interim crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the interim crown (D2799) provided on August 12, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on August 6, 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 (99214) rendered by the out-of-network (OON) provider on August 6, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 18, 2021.
You asked the Plan to pay for the laboratory services. 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.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for lens, polycarbonate (V2784) and photochromatic lenses (V2744) provided on August 2, 2021.  You asked the Plan to pay for lens, polycarbonate (V2784) and photochromatic lenses (V2744). You say that  The Plan denied your request. The Plan says polycarbonate lenses are typically prescribed for who are monocular (only one good seeing eye) to protect the better eye, or for those patients in fields where protective eyewear is highly recommended such as grinding metal. In addition, photochromatic lenses are typically prescribed for patients with severe photophobia due to eye conditions such as chronic dry eye syndrome. However, there was no clinical documentation of this member requires polycarbonate and photochromatic lenses  Medicare rules say use of polycarbonate or similar material (V2784) or high index glass or plastic  (V2782, V2783) for indications such as light weight or thinness will be denied as a noncovered deluxe feature. Medicare rules say tinted lenses (V2745), including photochromatic lenses (V2744), used as sunglasses, which are prescribed in addition to regular prosthetic lenses to a pseudophakic beneficiary, will be denied as noncovered.  We looked at the file and the Medicare rules. Medicare says use of polycarbonate for indications such as light weight or thinness will be denied as a noncovered deluxe feature. Medicare says photochromatic lenses used as sunglasses, which are prescribed in addition to regular prosthetic lenses to a pseudophakic beneficiary, will be denied as noncovered. Therefore, we decided that the Plan does not have to pay for lens, polycarbonate (V2784) and photochromatic lenses (V2744) provided on August 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87481, 87798, 88305, 88312) provided
on July 21, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that the patient was seen by a facility/physician that
is in-network. You also say that there was not an in-network laboratory or any alternative to be used who could
offer the appropriate medical treatment needed for the patient's care. You also say that the patient had no
control over the location in which their specimen was sent for processing. The Plan denied your request. The
Plan says this provider is out-of-network and the member was referred to this provider by an out-of-network
provider. The Plan also says that authorization was not obtained prior to the services being rendered and it was
determined the services were not urgent or emergent in nature.
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 laboratory services (87481, 87798, 88305, 88312)
provided on July 21, 2021 by an out-of-network (OON) provider.
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 May 8, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says because the member was not actually transported by ambulance, this expense is not covered by the members benefit plan.  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 May 8, 2021. 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 May 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for ophthalmological services, medical examination provided on July 9, 2021.  

You asked the Plan to pay for ophthalmological services, medical examination. The Plan denied your request. The Plan says the member does not have out-of-network vision benefits.  

Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   

We looked at the file and the Plan's rules. The file shows that the vision services were not provided by the Plan's vision provider. Based on this information, we decided that the Plan's rules for coverage of ophthalmological services, medical examination have not been met. Therefore, we decided that the Plan does not have to pay for ophthalmological services, medical examination provided on July 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient diagnostic testing services provided on July 8, 2021.  

You asked the Plan to waive the copayment for outpatient diagnostic testing services. The Plan denied your request. The Plan says the records indicate an outpatient diagnostic test was administered and the claim processed correctly.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for outpatient diagnostic tests and therapeutic services and supplies.   Y

ou have been asked to pay a $10 copayment for outpatient diagnostic testing services. The outpatient diagnostic testing services 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 outpatient diagnostic testing services provided on July 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for a hepatitis panel provided on July 15, 2021.  

You asked the Plan to pay for a hepatitis panel. The Plan denied your request. The Plan says with the information we have, we cannot determine how the member came to the servicing provider or whether the services are medically necessary.  

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. Therefore, we decided that the Plan does not have to pay for a hepatitis panel provided on July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on February 4, 2021.

You asked the Plan to pay for the core buildup. You say that the crown was pre-approved and at no time were you advised that the core buildup would not be covered by your insurance. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on February 4, 2021.

Your complaint about your disappointment in the Plan's coverage 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.