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

 We decided that the Plan does not have to pay for Neocate Junior provided from February 27, 2021, through August 5, 2021.  You asked the Plan to pay for Neocate Junior. You say that this is essential for your system as it helps to build weight since do not tolerate a diet low in histamine and your diet is very poor, very limited and you eat almost nothing because you have so many foods allergies. You say that you have tried other supplements but for having only one ingredient, your health has been affected. The Plan denied your request.  The Plan says this is a non-covered service, your referring physician is a non-contracted and there is no evidence of medical emergency or imminent life risk.  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 Neocate Junior. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for Neocate Junior provided from February 27, 2021, through August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), topical application of fluoride varnish (D1206) provided September 14, 2021.  You asked the Plan to pay for the periodic oral exam, dental cleaning and fluoride varnish. You say that you have previously been reimbursed for services and do not understand why you are not being reimbursed this time. The Plan denied your request. The Plan says these services are not covered because the provider has opted out of Medicare.  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 periodic oral exam, dental cleaning and fluoride varnish when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare.  We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the periodic oral exam, dental cleaning and fluoride varnish have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), topical application of fluoride varnish (D1206) provided September 14, 2021.   Your complaint about the Plan potentially providing inconsistent coverage of services 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services (D0274, D4342, D0150) provided August 17, 2021.  You asked the Plan to pay for the dental services. You say that the service should be covered. The Plan denied your request. The Plan says the benefit for this service has been exhausted.  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, coverage for a comprehensive dental exam is limited to once every 3 years. Records show this service was previously paid on January 8, 2020. Therefore, we decided that the Plan does not have to pay for dental services (D0274, D4342, D0150) provided August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the complex repair services coded 13132 provided on April 22, 2021.

You asked the Plan to pay for the complex repair services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.

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 13132 is a column II code to column I code 14040. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the complex repair services coded 13132 provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmology services you received on August 19, 2021.

You asked the Plan to waive the copayment for the ophthalmology services. You say that this was a diabetic retinopathy screening, so there should be no copayment. 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 $35 copayment for ophthalmology visits. 

You have been asked to pay a $35 copayment for the ophthalmology services. Diabetic retinopathy screening services should be billed with procedure codes 92227 and 92250. The services you received were billed with codes 92201 (ophthalmoscopy), 99204 (new patient office visit), and 92134 (scanning computerized ophthalmic imaging). The services you received are not considered diabetic retinopathy screening services. They are specialty ophthalmology services. That is why you were charged the $35 copayment for ophthalmology visits.

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 ophthalmology services you received on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services (97016, 97112, 97139, 87750), compound drugs (J3411, J3415, J3490, J7999), and administration (96372) provided on September 9, 2021.  You asked the Plan to pay for physical therapy services, compound drugs, and administration.. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.  The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. The rules also say that beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.  We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed exclusively with J7999, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Based on this information, we decided that Medicare rules for coverage of physical therapy services, compound drugs, and administration. have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (97016, 97112, 97139, 87750), compound drugs (J3411, J3415, J3490, J7999), and administration (96372) provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the cost sharing for the office visit you had with an out-of-network (OON) family practice doctor on July 15, 2021.  You asked the Plan to reduce the cost sharing for the OON office visit. You say that you saw this OON provider because your regular doctor left the facility and had not yet been replaced. You said that the facility brought in temporary doctors to see patients.  You said that you were not told that this doctor was OON, so this should be processed as in-network. The Plan denied your request. The Plan says you were charged the out-of-network cost sharing correctly.  This provider is out-of-network with the plan.  You did not contact the plan prior to receiving services to confirm the provider's network status.  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 50% coinsurance for out-of-network physician services.   You have been asked to pay 50% coinsurance for the OON office visit. Records show that you did not confirm this provider's network status with the Plan prior to this visit. 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 sharing for the office visit you had with an out-of-network (OON) family practice doctor on July 15, 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. Your rehab needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing facility after a trial on in-home therapies.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

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 complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient has a past medical history of hypertension, dementia nd frequent falls. She was seen in the Emergency Department on December 20, 2021, for a fall and head injury without loss of consciousness. She was discharged home. She had ongoing weakness and falls. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular profile testing provided on July 12, 2021.

You asked the Plan to pay for genetic testing. You say that this testing was a covered service. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is non-covered screening.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular profile testing provided on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), and 2D oral or facial photographic image (D0305 x 4) provided on September 28, 2021.  You asked the Plan to pay for the dental services. You say that you have not had a dental exam in over 1 year. You also say that these services should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 years. The Plan says 1 complete series or panoramic x-ray is covered every 5 years. The Plan says that these frequency limits have been exceeded. The Plan also says that 2D oral or facial photographic images are not listed as covered services.  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 comprehensive oral evaluation and complete series x-ray are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on August 15, 2019. The record shows that the Plan paid for a panoramic x-ray, which shares a frequency limit with a complete series x-ray, that you received on August 15, 2019. Additionally, 2D oral or facial photographic image are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), and 2D oral or facial photographic image (D0305 x 4) provided on September 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on July 13, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transport benefit and if no transport of a Medicare beneficiary occurs, then there is no Medicare-covered service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on July 13, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for core build-up (D2950) provided on September 16, 2021.

You asked the Plan to pay for core build-up. You say that you believed this was covered. The Plan denied your request. The Plan says this 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 core build-up (D2950) provided on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an orthopedic visit provided on March 4, 2021.  You asked the Plan to waive the copayment for an orthopedic visit. You say that you were told by the provider there would be no copayment for the visit. The Plan denied your request. The Plan says the correct copayment was 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 $30 copayment for each specialist visit for Medicare-covered benefits.     You have been asked to pay a $30 copayment for an orthopedic visit. Orthopedic visits falls 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 copayment for an orthopedic visit provided on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910), topical application of fluoride varnish (D1206), and localized delivery of antimicrobial agents (D4381) provided on May 25, 2021.  You asked the Plan to pay for the dental services. You say that the provider has opted out of the Medicare program. You say that the provider has not opted out of the enrollee's plan. You also say that the services should be covered for the enrollee. The Plan denied your request. The Plan says dental services performed by a provider that has opted out of Medicare are 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.  We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the file shows that provider in this case has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910), topical application of fluoride varnish (D1206), and localized delivery of antimicrobial agents (D4381) provided on May 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided August 27, 2021.  You asked the Plan to waive the copayment for the ambulance service and ground mileage. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says the copayment was 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 a $365 copayment for each Medicare-covered trip (one-way).  You have been asked to pay a $365 copayment for the ambulance services and ground mileage. The ambulance services and ground mileage fall within the Ambulance 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 ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) and the removal of impacted cerumen requiring instrumentation (69210) rendered by the out-of-network (OON) provider on September 16, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 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 the hospital outpatient clinic visit (G0463) and the removal of impacted cerumen requiring instrumentation (69210) rendered by the out-of-network (OON) provider on September 16, 2021.