Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transportation (A0427) provided on April 19, 2020.  

You asked the Plan to pay for the ground mileage and emergency ambulance transportation. You say that the pickup zip code is, and always has been, properly on the claim. You also say that the Plan is aware of the glitch and you should not have to appeal for the Plan's error. The Plan denied your request. The Plan says the original claim has a processed date of April 30, 2020 and this corrected claim was received on August 3, 2021. The Plan also says that this is past the allowed 12-month timeframe.  

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  

The record shows that a claim for the ground mileage and emergency ambulance transportation was not filed until August 3, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transportation (A0427) provided on April 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to reduce the cost for outpatient surgery services provided on January 15, 2021.  You asked the Plan to reduce the cost for the outpatient surgery services. You say that the denial for inadequate paperwork from the provider is not your fault and you should not be liable. You say that the amount of you share is outrageous and this issue should be resolved. The Plan denied your request. The Plan says you are only being billed the $195 copayment.  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 $195 copayment for outpatient surgery services at an in-network outpatient hospital.     You have only been asked to pay a $195 copayment for the outpatient surgery services provided on January 15, 2021. The outpatient surgery services fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the cost for outpatient surgery services provided on January 15, 2021.   Please note that the Explanation of Benefits issued to you for this claim contains inaccurate information regarding the amount you owe for the outpatient surgery services. Please contact the health plan to receive a corrected Explanation of Benefits
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing rendered on August 20, 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 an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on August 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on August 18, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for periodontal maintenance. You say that you are requesting reconsideration of payment for this procedure as it consists of a thorough cleaning of your teeth which is needed every six months. You also say you would like the Plan to cover the regular cleaning portion of the amount owed. The Plan denied your request. The Plan says the requested service is not a covered benefit with your Plan.
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 periodontal maintenance (D4910) provided on August 18, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on August 4, 2021, to September 17, 2021.  

You asked the Plan to waive the copayment for physical therapy. You say that you were told your copayment would be $15. The Plan denied your request. The Plan says the correct copayments has been applied.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for outpatient rehabilitation services/physical therapy.   

You have been asked to pay a $40 copayment for each physical therapy. The total amount you are being asked to pay is $520 ($40 x 13 visits = $520). The correct copayment has been applied to the physical therapy that was provided. Physical therapy falls within the outpatient rehabilitation services/physical therapy 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 physical therapy provided by a participating provider on August 4, 2021, to September 17, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for a visit provided by a psychology doctoral practitioner on August 24, 2021.  

You asked the Plan to pay for psychology visit. You say that you are appealing with supporting records to prove medical necessity. The Plan denied your request. The Plan says the denial of payment for this service is correct, because there is no referring physician on the claim and the record does not show an attempt to consult the attending or primary care physician.  

The Plan must follow Medicare rules. Medicare rules say that coverage of a psychology doctoral practitioner requires that the provider must attempt to consult the enrollee's attending or primary care physician.   

We looked at the file and Medicare rules. The record does not include a consultation or attempt to consult the enrollee's attending or primary care physician. Based on this information, we decided that Medicare rules for coverage of psychology visit have not been met. Therefore, we decided that the Plan does not have to pay for a visit provided by a psychology doctoral practitioner on August 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional PT visits.

You asked the Plan to pre-approve eight (8) additional PT visits. The Plan denied your request. The Plan says eight (8) additional PT visits are 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 eight (8) additional PT visits. 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 the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate 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 by or under the supervision of a therapist. The enrollee has been given additional therapy to transition to a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee'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 eight (8) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional PT visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on April 19, 2021.  You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because the services rendered were medically reasonable and necessary. The Plan denied your request. The Plan says there is no referring physician listed on the claim.  The Plan must follow Medicare rules. Medicare rules say that when services are rendered by a Clinical Psychologist, if the patient consents, you must attempt to consult their attending or primary care physician about the provided services and document the consent or declination date to consultations and date of the consultations in the patient's medical record.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met.  Specifically, the claim does not include a referring provider and the medical documentation submitted does not indicate that an attempt was made to consult the member's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90832) provided on April 19, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care, provided on August 1, 2021, through August 4, 2021.  You asked the Plan to pay for the SNF care. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not medically necessary.  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 pay for the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require any skilled nursing or skilled therapy services.  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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means that SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care, provided on August 1, 2021, through August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment applied to a specialist office visit provided on August 24, 2021.  

You asked the Plan to waive the copayment applied to the specialist office visit. You say that this was a follow-up visit. You say that the visit was within 10 days of your surgery and you should not be charged. The Plan denied your request. The Plan says the copayment was appropriately applied to the services provided.  

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 consultation, diagnosis, and treatment by a specialist.     

You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the Consultation, Diagnosis, and Treatment by a Specialist 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 applied to a specialist office visit provided on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pre-approve a pontic (D6245) for tooth #30 and retainer crowns (D6740) for tooth #'s 29 and 31.  You asked the Plan to pre-approve the bridge. You say that the bridge hurts, one side is broken off, and one of the teeth are exposed. You also say that your provider determined it is necessary for the bridge to be replaced because it cannot be fixed. The Plan denied your request. The Plan says that it is not medically necessary to replace your fixed partial denture, including the tooth-shaped piece that fits over your tooth and the fake teeth.  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 bridge 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 bridge. Our reviewer says that the documentation meets the criteria for coverage for a replacement fixed bridge replacing missing tooth #30 using tooth #'s 29 and 31 as abutment retainers. Our physician reviewer found the current fixed bridge is fractured and not repairable. Our reviewer also found that a replacement fixed bridge is medically reasonable and necessary to provide you with adequate comfort and function.  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 bridge have been met. Therefore, we decided that the Plan has to pre-approve a pontic (D6245) for tooth #30 and retainer crowns (D6740) for tooth #'s 29 and 31.   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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 3 additional skilled nursing (SN) visits (G0299).  You asked the Plan to pre-approve the additional SN visits. The Plan denied your request. The Plan says the enrollee does not currently meet the criteria for the requested number of skilled nursing visits for catheter care and wound care.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional SN visits. Our reviewer says that the 3 additional skilled nursing visits (G0299) are not shown to be medically necessary or reasonable. Our physician reviewer found you require monthly catheter changes and daily pericare. Our reviewer found that the health plan approved two home health skilled nursing visits for the catheter changes. Our physician reviewer also found that the daily pericare is not complex and can be provided by a layperson.  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 skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 additional skilled nursing (SN) visits (G0299).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin-based composite (D2331) provided on September 2, 2021.  

You asked the Plan to pay for the resin-based composite. You say that when you joined this Plan the insurance agent told you that fillings were covered. You also say that this filling is a preventive procedure. The Plan denied your request. The Plan says this restorative service is not covered. The Plan also says that you chose not to purchase the optional supplemental benefits which would have added comprehensive dental benefits to your plan.  

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 resin-based composite (D2331) provided on September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the digital hearing aids (V5261) purchased on June 7, 2021, from an out-of-network provider.  You asked the Plan to pay for the hearing aids. You say that the information you received from the first provider was incorrect and you decided to use another provider for the hearing aids. You feel you should be reimbursed even though these services were provided out-of-network because it is the same cost for the Plan. The Plan denied your request. The Plan says hearing aids purchased outside of the Plan's specified hearing vendor network are not covered.  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. The Plan pays for hearing aids only when they are purchased from a provider in the Plan's hearing vendor network.   We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's specified network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the digital hearing aids (V5261) purchased on June 7, 2021, from an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional supplies, materials and clinical staff time coded as 99072 provided from August 11, 2021, through August 20, 2021.  

You asked the Plan to pay for the medical services. You say that these services were billed correctly. The Plan denied your request. The Plan says payment for these services is always bundled into payment for other services not specified.  

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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.  

We looked at the file and Medicare rules. In this case, code 99072 has a Status Code of "B" which indicates that it is a Bundled Code. This means that payment for covered services are always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met.   Therefore, we decided that the Plan does not have to pay for the additional supplies, materials and clinical staff time coded as 99072 provided from August 11, 2021, through August 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the power seat elevation system (CPT code E2300), for the enrollee.  You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. The Plan says this item is not covered. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the item have not been met. The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation system (CPT code E2300), for the enrollee.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services received on September 11, 2021.  You asked the Plan to pay for the services. You say that these services are for emergent conditions per law. The Plan denied your request. The Plan says the medical records received show the main issue was tooth pain and soreness from that.  Medicare generally does not cover dental services. The Plan follows the same rule.  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services received on September 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; whole body (CPT code 78816), for the enrollee.  You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the service is not necessary.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the service. Our physician reviewer found this enrollee had a magnetic resonance imaging (MRI) then a CT scan that did not indicate a rationale for which a PET scan would be indicated. Work-up of abdominal and back pain is not a covered indication for a PET scan after an MRI and CT scan that did not show significant findings for which a PET would be needed. The service is not 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; whole body (CPT code 78816), for the enrollee.