Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the IRF services are medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the requested IRF services.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found There are no complex nursing or rehabilitation needs. The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this member will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) and panoramic x-ray
(D0330) provided on August 10, 2021.
You asked the Plan to pay for the exam and x-ray. You say that you went in for a dental cleaning, and you did
not request these services, nor were you informed that they would not be covered by your Plan. The Plan
denied your request. The Plan says panoramic x-rays are not covered by your dental benefit, and you had a
previous comprehensive oral exam in August of 2020 which was covered at that time. Your dental benefit can
cover one comprehensive or periodontal exam every three years; therefore, your benefit for this service was
exhausted on the date in question.
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 panoramic x-ray is not
among those covered under this benefit, and the comprehensive oral exam is requested in a frequency that
exceeds what is covered by this benefit. Documentation shows that you had a previous comprehensive oral
exam less than three years before the date in question, which was covered by the Plan at that time. Therefore,
we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) and panoramic x-ray
(D0330) provided on August 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on June 24, 2020.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available 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 code is not appropriate for the service billed.
The Plan must follow Medicare rules. Medicare rules say that services of a physical/occupational 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 physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner. As such, 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 physical therapy services provided by a physical therapist on June 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the angiography services (75716 and 75774) provided on
April 21, 2021.
You asked the Plan to pay for the angiography services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says an edit exists between 75716, 75774 and
37225.
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 asked our coder 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 angiography services. Our reviewer says that CPT code
75716 does not meet criteria for billing or reimbursement consideration. The operative report does not support
modifier 59 as a distinct procedure service from CPT 37225, as CPT 37225 includes radiological supervision
and interpretation, and billing both procedures results in duplicate billing. Our reviewer found CPT code 75774
does not meet criteria for billing or reimbursement consideration. The operative report does not support
modifier XS separate structure from CPT 37225, and therefore cannot be confirmed. When reporting a codes
normally inclusive to another code, with a modifier to report codes separately, documentation should be
submitted to clarify the rationale of services unbundled.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the angiography services have not been met. Therefore, we decided that the
Plan does not have to pay for the angiography services (75716 and 75774) provided on April 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided from July 2, 2021, through
July 16, 2021.
You asked the Plan to pay for physical therapy. The Plan denied your request. 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. We have also determined that these services are not urgent or emergent, nor were they approved in advance.
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 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 physical therapy provided from July 2, 2021, through
July 16, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and extractions (D7140 x 2) provided on June 18, 2021, by an out of network provider.
You asked the Plan to reimburse you for the dental services. You say that you recently purchased dental coverage that was to pay up to 50% for extractions. You also say that only 13% was sent to you. The Plan denied your request. The Plan says 2 extractions are covered per calendar year with a 55% coinsurance when received out of network. The Plan says there is a 50% coinsurance for an emergency exam when received out of network.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, out of network dentist may bill you for any amount greater than what the Plan pays the provider.
Procedure Code
Billed Amount
Allowed Amount
Difference
Coinsurance
Plan Paid
Your Responsibility
D0140
$150
$33
$117
$16.50
$16.50
$133.50
D7140
$220
$68
$152
$37.40
$30.60
$189.40
D7140
$220
$68
$152
$37.40
$30.60
$189.40
TOTAL:
$512.30
Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and extractions (D7140 x 2) provided on June 18, 2021, by an out of network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse an additional amount for the extractions (D7210 x 2) provided on March 3, 2021.
You asked the Plan to reimburse an additional amount for the dental services. You say that you were received a check for $192. You say that you should have been reimbursed an additional $383. You also say that a plan representative advised by a plan representative that the provider should have have charged you for the services. The Plan denied your request. The Plan says the dentist in this case is out of network. The Plan also says that dental services you receive out of network dentists are paid based on the allowed amount and not what the amount that the provider bills.
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, dental services received out of network may have a higher cost sharing amount. Therefore, we decided that the Plan does not have to reimburse an additional amount for the extractions (D7210 x 2) provided on March 3, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay toward for the fillings provided on August 9, 2021 and the limited oral evaluation, intraoral x-ray and unspecified preventive procedure provided on August 16, 2021.
You asked the Plan to pay toward for the fillings, limited oral evaluation, intraoral x-ray and unspecified preventive. You say that you know you get a certain amount of money to help with this and you don't understand why payment was denied. The Plan denied your request. The Plan says the claims processed correctly.
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 Plan is only obligated to pay 50% of the allowed amount for the fillings, limited oral evaluation and intraoral x-ray after your $100 deductible has been met. The unspecified preventive procedure remains denied as a non-covered benefit. Therefore, we decided that the Plan does not have to pay toward for the fillings provided on August 9, 2021 and the limited oral evaluation, intraoral x-ray and unspecified preventive procedure provided on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) and unspecified
removable prosthodontic service (D5899) provided on July 7, 2021.
You asked the Plan to pay for the unspecified removable prosthodontic service. You say that you were advised
that you did not have dental insurance in 2017 so it could not have been 5 years. The Plan denied your request.
The Plan says the unspecified removable prosthodontic service 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 unspecified removable prosthodontic service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and unspecified removable prosthodontic service (D5899) provided on July 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on July 8, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the drug testing provided on July 8, 2021, by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral exam (D0150) provided June 14, 2021.
You asked the Plan to pay for the dental service. You say that you went to the dental appointment after you had
paid $94 and then found out that they do not do dentures. The Plan denied your request. The Plan says this
service exceeds the benefit frequency limitation.
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. This service is covered once
every three plan years. The records show that this service was provided for date of service March 25, 2021
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
comprehensive oral exam (D0150) provided June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 13, 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 the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 13, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on April 6, 2021.
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says there is no coverage if hearing aids, or related services are received from a provider not part of the Plan's hearing aid vendor's network.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid 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 hearing aids were not provided by the Plan's hearing aid vendor's network. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on April 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 28, 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 billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in a nursing facility setting and should have been billed with POS code 32. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prolotherapy, a transcutaneous electrical nerve stimulator (TENS) device and supplies and a pneumatic device provided on August 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for prolotherapy, a transcutaneous electrical nerve stimulator (TENS) device and supplies and a pneumatic device. You say that say the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says these services are not covered by Medicare. 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. Medicare rules say that items and services that are not medically necessary are not covered. 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 prolotherapy, a transcutaneous electrical nerve stimulator (TENS) device and supplies and a pneumatic device provided on August 11, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the extremity study you had on June 18, 2021.
You asked the Plan to waive the copayment for the extremity study. You say that this should be covered by your plan with no money due from you. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($83.05) is less than your copayment obligation, you are responsible for the full allowed 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 a $125 copayment for the extremity study. The extremity study falls within the radiological diagnostic 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 extremity study you had on June 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Zilretta injection you received on August 31, 2021.
You asked the Plan to waive the coinsurance for the Zilretta injection. You say that you were not told the doctor was changing your medication, and it resulted in an increased charge for you. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the Zilretta injection. The Zilretta injection falls within the Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Zilretta injection you received on August 31, 2021.
Your complaint about the doctor's office not telling you about the medication change is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental gradient pneumatic appliance (E0673) provided June 24, 2021.
You asked the Plan to pay for a pneumatic compression device and appliance. You say that the enrollee's physician had prescribed the use of a pneumatic compression device to prevent the formation of blood clots. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental gradient pneumatic appliance (E0673) provided June 24, 2021.