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

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
May 3, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee 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 must 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 to the 
enrollee on May 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration.
You asked the Plan to pre-approve bone marrow aspiration. 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 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 bone marrow aspiration. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found bone marrow aspirate remains experimental. More research is needed to show safety
and efficacy of bone marrow aspirate when used as bone graft material.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan
does not have to pre-approve bone marrow aspiration.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the procedure to implant a defibrillator 
you had at an outpatient hospital facility on June 2, 2021. 
 
You asked the Plan to waive the coinsurance for the outpatient surgery. You say that you were admitted to the 
hospital so you were not told that you were an outpatient. 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 surgery in an outpatient hospital.  
 
You have been asked to pay 20% coinsurance for the outpatient surgery. The records show that you were an 
outpatient in the hospital. 

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 procedure to implant a defibrillator you had at an 
outpatient hospital facility on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) provided March 3, 2021.
You asked the Plan to pay for the eye refraction. You say that the eye refraction was performed post cataract surgery and should be covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services once per calendar year. We looked at the file and the Plan's rules. The Plan provided documentation showing that an eye refraction was previously covered on January 27, 2021. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) provided March 3, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (76937) provided June 5, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the service at issue shares a bundled relationship with another service 
billed. 
 
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, we have confirmed that code 76937 
has a bundled relationship with code 93971 and cannot be paid as billed. This code cannot be paid as a separate 
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided 
that the Plan does not have to pay for radiology services (76937) provided June 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88104) provided May 12, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code shares a bundled relationship with another code billed.
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, we have confirmed that code 88104 has a bundled relationship with code 88112 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for lab services (88104) provided May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry services provided July 17, 
2021. 
 
You asked the Plan to waive the copayment for the podiatry services. You say that you do not believe you 
should be charged a copayment. The Plan denied your request. The Plan says the copayment has processed 
correctly in this case. 
 
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 Medicare-covered podiatry services.  
 
You have been asked to pay a $35 copayment for the podiatry services. This service falls within the Medicare-
covered podiatry services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the podiatry 
services provided July 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided you do 
not require the services on an inpatient basis, only in a skilled nursing facility setting. Given your ongoing 
issues with confusion and refusal/inability to participate with therapy, further treatment and stabilization of the 
encephalopathy appears indicated prior to transfer to skilled nursing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on August 26, 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 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 the services of a physical therapy assistant (PTA) 
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 the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA 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 therapy assistant on August 26, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the ultrasonic guidance for needle placement (76942) billed with a -26 
modifier provided on March 2, 2021. 
 
You asked the Plan to pay for the ultrasonic guidance for needle placement. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says that the claim has 
been billed with an incorrect modifier. 
 
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 76942 is ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), 
imaging supervision and interpretation. 
 
We find that CPT code 76942 with a -26 modifier is supported in the medical record. Specifically, while it may 
be that the provider is entitled to payment of both the PC and TC for this service, there is nothing in the rules 
which could be construed to say that the Plan must bill for the TC. In this case, the provider has billed the PC 
for this code and as per the rules, the Plan must pay for it "in all settings".  Based on this information, we 
decided that Medicare rules for coverage of the ultrasonic guidance for needle placement have been met. 
Therefore, we decided that the Plan has to pay for the ultrasonic guidance for needle placement (76942) billed 
with a -26 modifier provided on March 2, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the chest x-ray, outpatient clinic visits, 
office visits and cardiovascular monitoring provided from April 5, 2021, through April 22, 2021. 
 
You asked the Plan to reduce the coinsurance for the chest x-ray, outpatient clinic visits, office visits and 
cardiovascular monitoring. You say that you were not informed the doctors were out-of-network. You say that 
the outstanding charges should be canceled, and you should be refunded the extra fees because you were not 
informed the providers were out-of-network. The Plan denied your request. The Plan says the out-of-network 
coinsurance applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% of 
the total cost for x-rays, outpatient diagnostic tests, outpatient hospital services and physician services from 
out-of-network providers. 
 
You have been asked to pay a total of $251.14 for the chest x-ray, outpatient clinic visits, office visits and 
cardiovascular monitoring. 

The chest x-ray and cardiovascular monitoring fall within the "Outpatient diagnostic tests and therapeutic 
services and supplies" benefit category. The outpatient clinic visits fall within the "Outpatient hospital services" 
benefit category. The office visits fall within the "Physician/Practitioner services, including doctor's office 
visits" benefit category. The records show the provider is out-of-network. 
 
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 coinsurance for the chest x-ray, outpatient clinic visits, office visits and 
cardiovascular monitoring provided from April 5, 2021, through April 22, 2021.  
 
Your complaint about being mistreated and mishandling by the provider 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.

You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says you have used 24 of the 24 trips and have 0 trips remaining in 2021.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).

You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan says the certification dated September 28, 2021, documented that the enrollee has none of the qualifying diagnoses, does not require intense care coordination, and has no high risk for hospitalizations or high risk for adverse health outcomes.

The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. 

We looked at the file and Plan's rules. The file shows that your medical conditions are not eligible medical conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 a Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has multi-level lumbar disease, including severe spinal stenosis. The record does not indicate that the enrollee is not indicated for operative treatment at no more than two levels. The record does not indicate that the enrollee obtains relief in flexion. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on December 16, 2019.
You asked the Plan to pay for 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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Specifically, medical records for the services provided on December 16, 2019 were not submitted. This means that we cannot determine if the criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on December 16, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and management of an established patient (99213) provided on December 8, 2020.
You asked the Plan to pay for the evaluation and management service. You say that the enrollee was seen on the same day that they were admitted to hospice. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the
provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. The hospice benefit is based on the dates of enrollment, and is not time specific. Therefore, we decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and management of an established patient (99213) provided on December 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional physical therapy (PT) visits.
You asked the Plan to pre-approve 6 additional PT visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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 6 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 instructed in 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 6 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional physical therapy (PT) visits