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

We decided that the Plan does not have to waive the copayments for specialist visits provided on May 19, 2021, and June 2, 2021.
You asked the Plan to waive the copayments for specialist visits. You say that you called to see your primary care provider but they were not available so you made an appointment with another provider without being informed that you would owe a higher copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $45 copayment for each specialist visit. The record shows that you received specialist services on May 19, 2021. Therefore, you are responsible to pay the $45 copayment. The record shows that you received specialist services on June 2, 2021. Therefore, you are responsible to pay
the $45 copayment. The total amount you owe is: $90. You have been asked to pay the total copayment amount of $90 for specialist visits. Specialist visits fall 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 copayments for specialist visits provided on May 19, 2021, and June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry visit you had on March 10, 2021.

You asked the Plan to waive the copayment for the podiatry visit. You say that diabetic nail clippings are free so you should not be charged for this service. The Plan denied your request. The Plan says you were not charged a copayment for the nail clipping service. The Plan says that you had an office visit that exceeded the nail clipping, which is why the copayment was charged.

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 podiatry visits. 

You have been asked to pay a $40 copayment for the podiatry visit. The medical records from this podiatry visit show that in addition to toenail trimming, your podiatrist performed a full diabetic foot exam. Since a diabetic foot exam is beyond the scope of nail clipping, the visit falls within the podiatry 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 podiatry visit you had on March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the addition of a tooth to an existing partial denture (D5650) provided on May 6, 2021.

You asked the Plan to pay for the addition of a tooth to an existing partial denture. You say that you have a $2,000 allowance per year under your dental plan which covers fillings, root canals, crowns, partial bridges, dentures, and more. You also say that the tooth needed to be placed on your denture because your only remaining original tooth had to be pulled. The Plan denied your request. The Plan says this service is not a covered benefit under 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. The record shows that the Plan confirmed with the provider that you were made aware of which services were covered and non-covered and you agreed to have the non-covered services completed and pay up front. Therefore, we decided that the Plan does not have to pay for the addition of a tooth to an existing partial denture (D5650) provided on May 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.

You asked the Plan to pre-approve additional physical therapy visits. You say that the patient is unable to perform mechanical traction as part of a home exercise program. You say that she would benefit from additional visits in order to maximize functional mobility and safety. The Plan denied your request. The Plan says additional 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 additional physical therapy 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 that the patient has had prior therapy, has been instructed in a home exercise program and has transitioned to the home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services related to an outpatient knee replacement revision (27487) provided from December 1, 2020, through December 23, 2020.

You asked the Plan to pay for the outpatient knee replacement revision surgery. You say that this cannot be billed as inpatient as the enrollee was not formally admitted. This should be paid as an outpatient procedure. The Plan denied your request. The Plan says payment cannot be made as this code is inpatient-only in the 2020 OPPS. Payment could be considered if an inpatient claim were submitted.

The Plan must follow Medicare rules. Medicare rules say that certain procedures are not payable through the OPPS as they are considered inpatient-only.

In 2020, code 27487 had an OPPS status indicator of "C". This means it cannot be paid on an outpatient hospital claim. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services related to an outpatient knee replacement revision (27487) provided from December 1, 2020, through December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower denture (D5120) provided on April 13, 2021.

You asked the Plan to pay for the dental services. You say that the dentures you received last year were poorly made. You say that you were in and out of the hospital and as a result were not able to return to get them fixed. You say that you did not want to return to the previous location. You also say that your new dentures fit fine. The Plan denied your request. The Plan says dentures are covered once every 5 plan years. The Plan also says that the frequency limit has 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 dentures are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for dentures that you received on May 28, 2019. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower denture (D5120) provided on April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additional intraoral periapical x-rays (D0230 x2) and consultation (D9310) provided on May 12, 2021.

You asked the Plan to pay for the additional intraoral periapical x-rays and consultation. You say that you were not advised that you had to go to an in-network dentist. You also say that you cannot afford to pay for these services. The Plan denied your request. The Plan says consultations are not a covered service. The Plan also says that services performed by an out-of-network provider are not covered because your healthcare plan does not have out-of-network benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, consultation is not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) on May 12, 2021 which was covered by the Plan and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the two additional intraoral periapical x-rays (D0230 x2) and consultation (D9310) provided on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for immunizations provided on March 15, 2021 by an out-of-network provider.

You asked the Plan to pay for immunizations (90715, 90732, 90741, G0009). You say that the services were medically necessary. The Plan denied your request. The Plan says you did not request 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 requested 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 immunizations provided on March 15, 2021 by an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on February 19, 2021.

You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were rendered to the enrollee in good faith. The Plan denied your request. The Plan says rules for psychotherapy services have not been met.

The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the patient's attending or primary care physician. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the case record does not contain documentation of a consultation or attempted consultation with the enrollee's primary care or attending physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on March 17, 2021.

You asked the Plan to pay for the panoramic x-ray. You say that you contacted the Plan and verified your dental benefits before you used it. The Plan denied your request. The Plan says your benefits for the panoramic x-ray have been satisfied and the frequency limitation has 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, full mouth or panoramic x-rays share a frequency limitation of one procedure code every five years. The record shows that you received a complete series of intraoral x-rays on February 16, 2021 and your full mouth or panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on March 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider from February 25, 2021, through March 8, 2021.

You asked the Plan to pay for physical therapy. You say that you attached the pertinent documents for these visits. You say that the denial should be reconsidered, and coverage approved for the services rendered. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not 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 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 physical therapy provided by an out-of-network provider from February 25, 2021, through March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth optometrist services provided on February 17, 2021 by an out-of-network provider.

You asked the Plan to pay for the telehealth optometrist services (92065, 99213). You say that you would like the Plan to allow you to be in-network and pay this claim. The Plan denied your request. The Plan says you did not request prior authorization as required.

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 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 items/services. Therefore, we decided that the Plan does not have to pay for the telehealth optometrist services provided on February 17, 2021 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shipping and handling (99199) and sales tax (S9999) for a power operated vehicle provided on March 23, 2021.

You asked the Plan to pay for shipping and handling or sales tax. You say that you were informed by representatives of the Plan that the requested items were covered under the Plan. The Plan denied your request. The Plan says the request reimbursement is not a Medicare benefit.

The Plan must follow Medicare rules. Medicare rules say that Medicare does not reimburse separately for sales tax. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of shipping and handling and sales tax have not been met. Specifically, Medicare does not reimburse separately for shipping and handling or sales tax. Therefore, we decided that the Plan does not have to pay for shipping and handling (99199) and sales tax (S9999) for a power operated vehicle provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a dermatologist on May 27, 2021.

You asked the Plan to waive the copayment for the dermatology visit. You say that you have never had to pay a copayment for this in the past. 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 $30 copayment for visits with a specialist. 

You have been asked to pay a $30 copayment for the dermatology visit. The dermatology visit falls within the visits with 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 for the office visit you had with a dermatologist on May 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Medicare Part B and chemotherapy drugs provided on March 30, 2021.

You asked the Plan to waive the coinsurance for the drugs. You say that this cost should not be your responsibility. The Plan denied your request. The Plan says that there is a 20% coinsurance for these drugs.

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 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance for the drugs. The drugs fall within the Medicare Part B prescription 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 Medicare Part B and chemotherapy drugs provided on March 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for catheter placement (code 36215) provided on April 1, 2021.

You asked the Plan to pay for catheter placement. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the documentation submitted does not support this code and it is considered inclusive to code 36902.

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 36215 is selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family. 

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 catheter placement. Our reviewer says that this code does not meet the criteria for payment. Our reviewer found no documentation was found to report code 36215 for evaluation for inflow stenosis separately from code 36902.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of catheter placement have not been met. Therefore, we decided that the Plan does not have to pay for catheter placement (code 36215) provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex Superion interspinous spacer device would not be considered a standard of care for the enrollee's condition and is not medically reasonable and necessary in this case. Studies regarding the device are at high risk of bias due small sample sizes, retrospective design, and lack of randomization and independent controls.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgical pathology provided on January 8, 2021.

You asked the Plan to waive the copayment for surgical pathology. You say that your physician took a biopsy and the Plan should be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $15 copayment for lab services. 

You have been asked to pay a $15 copayment for surgical pathology. Surgical pathology 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 surgical pathology provided on January 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network physician services provided on April 27, 2021.

You asked the Plan to pay for these services. You say that you believe these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.

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 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 out of network physician services provided on April 27, 2021 by N. Stadlan, MD.