Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete
series x-ray (D0210) provided on June 28, 2021.
You asked the Plan to pay for the dental services. You say that you never received an oral evaluation. You say
that no one even looked in your mouth. You say that you cannot have a deep cleaning for medical reasons. You
also say that you have not found a provider that will do a regular cleaning. The Plan denied your request. The
Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says 1 complete series x-ray
is covered every 3 plan years. The Plan also says that the frequency limits have been exceeded.
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,
the frequency limits have been exceeded. The record shows that the Plan paid for these services that you
received on September 27, 2019. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on June 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services (A0429) provided on May 12, 2021.

You asked the Plan to waive the copayment for ambulance services. You say that you are being billed for a service you objected to at the time. The Plan denied your request. The Plan says you were charged this cost sharing 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 $250 copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $250 for these services. 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 ambulance services (A0429) provided on May 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the lower extremity you had on March 24, 2021.

You asked the Plan to waive the copayment for the MRI. You say that you were never told about this cost sharing and you did not know how the copayment works. 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 diagnostic radiology services. 

You have been asked to pay a $50 copayment for the MRI. The MRI falls within the diagnostic radiology 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 magnetic resonance imaging (MRI) of the lower extremity you had on March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intermittent urinary catheter (A4353) on April 29, 2021.

You asked the Plan to pay for the catheter supplies. You say that the supplies should be covered. The Plan
denied your request. The Plan says the billed services were not supported by the delivery ticket.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.

The record does not contain a valid proof of delivery to support medical necessity for the supplies provided in
this case. The delivery ticket indicates other supplies and is not specific as to the supply code or descriptions of
the services provided. The record shows that the Plan made several attempts to obtain the necessary
documentation without success. Therefore, we decided that the Plan does not have to pay for the intermittent
urinary catheter (A4353) on April 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on January 7, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that this visit was medically necessary, and there was no time to check the network status. The Plan denied your request. The Plan says the enrollee has no OON benefits.

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 the domiciliary or rest home visit provided on January 7, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day reader device. 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day reader device. 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. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a
Freestyle Libre 14-day reader device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre 14-day reader device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on October 1, 2019. 
 
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 if services are not available in the service area. You say that 
the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. 
The Plan says the records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist (PT) billed as 
services incident to a physician/non-physician practitioner's service must meet all incident requirements. 
Medicare rules say that the services of a physical therapy assistant shall not be billed as services incident to a 
physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner. As such, PT 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 on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on June 17, 2021.

You asked the Plan to pay for these services. You say that The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. The file shows that the Plan covered the manual manipulation of the spine services less your contractual copayment. The provider also submitted a claim for procedure code 99203 (office visit), which is not covered when billed by a chiropractor in conjunction with Medicare-covered chiropractic services. Therefore, we decided that the Plan does not have to pay for the office visit rendered on June 17, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for neuropsychological testing evaluation services provided by a 
psychology doctoral (Ph. D) provider on June 1, 2021. 
 
You asked the Plan to pay for neuropsychological testing evaluation. You say that the coding is correct and you 
are submitting records to support these services. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because there is no documented contact with the attending/primary care 
provider and no referring physician listed on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that services performed by a Psychology Doctoral 
degree are only covered under certain circumstances, including that the provider must attempt to consult the 
enrollee's attending or primary care physician about services.  
 
We looked at the file and Medicare rules. These services were performed by a Psychology Doctoral degree, and 
the records submitted do not show that any attempt was made to consult the enrollee's attending or primary 
care physician about these services. Based on this information, we decided that Medicare rules for coverage of 
neuropsychological testing evaluation have not been met. Therefore, we decided that the Plan does not have to 
pay for neuropsychological testing evaluation services provided by a psychology doctoral (Ph. D) provider on 
June 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that this request is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 February 20, 2021.

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 if services are not available in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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 February 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a rollator walker provided on May 21, 2021 by a nonparticipating provider.

You asked the Plan to pay for the walker. You say that this walker works very well for you, and you had no success getting one from the Plan. The Plan denied your request. The Plan says they will not pay for excluded services.

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 a rollator walker provided on May 21, 2021 by a nonparticipating provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapist on November 25, 2019. 

You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate if services are not available in the service area. You say that 
the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. 
The Plan says the records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services of an 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 occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner. As such, occupational therapy services cannot be paid incident to this provider's professional 
services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided 
by an occupational therapist on November 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on August 2, 2021. 
 
You asked the Plan to pay for the consultation. You say that you had the consultation because part of a tooth 
and its gum has grown infected. The Plan denied your request. The Plan says this service is not covered. 
 
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 
consultation (D9310) provided on August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee
April 13, 2021.

You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent
deep vein thrombosis. The Plan denied your request. The Plan says the 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 is a preventive service. Claims for E0675 will be denied as
not reasonable and necessary.

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.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for a pneumatic compression device provided to the enrollee April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing provided on May 5, 2021.

You asked the Plan to pay for the testing services. You say that the testing monitors for recurrence of bladder cancer. The Plan denied your request. The Plan says the clinical effective has not been demonstrated in peer reviewed literature.

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 pay for the testing services. Our physician reviewer found that the enrollee is stated to have had bladder cancer several years ago. Her last cystoscopy in October 2020, was negative. She has no symptoms. The National Comprehensive Cancer Network (NCCN) guidelines recommends consideration of urinary urothelial tumor markers (category 2B) for high-risk non-muscle invasive bladder cancer. There is no documentation that this enrollee fits these criteria. Therefore, the services were 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 testing services have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing provided on May 5, 2021.
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 the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 the enrollee's medical problems are stable and there are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 

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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95886) provided on March 17, 2021.
You asked the Plan to pay for needle electromyography. You say that you are appealing with supporting record. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the primary code 95910 is not supported and therefore this add-on code is also not supported.
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 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure).
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 needle electromyography. Our reviewer says that this code
does not meet the criteria for payment. Our reviewer found code 95886 is an "add-on" code and is payable if
the primary code is approved for reimbursement. In this case, the primary procedure code was denied because
service was not documented as performed. Therefore, code 95886 would also not be covered.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of needle electromyography have not been met. Therefore, we decided that the
Plan does not have to pay for needle electromyography (95886) provided on March 17, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 11, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the Plan should not pay this bill and you were there for a physician visit only. You say you paid $50 for the office visit. 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 services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on May 11, 2021, by an out-of-network (OON) provider