Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that you made progress, but the progress has stopped. You say that you can return to normal range with no pain with continued physical therapy. 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 10 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 you had prior therapy and have been instructed in a 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 10 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 22, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you thought that your dentist was listed as an in-network provider with the Plan. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.
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, you are responsible for 100% of the
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 22, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 8, 2021 by an out-of-network provider.
You asked the Plan to pay for the follow-up office visit. You say that the provider performed the procedure in good faith so as not to be a barrier to medical care. The Plan denied your request. The Plan says prior authorization was not requested 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit provided on April 8, 2021 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 15, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says predictive screening testing is not a covered benefit.

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. 

We looked at the file and the rules. The testing services provided were requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional 20 units of propofol (J2704) provided on June 5, 2019.
You asked the Plan to pay for an additional 20 units of propofol. You say that this should be paid as billed. The Plan denied your request. The Plan says this was previously paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.
We find that an additional 20 units of CPT code J2704 are not supported in the medical record. The record shows that 20 units of this code were previously paid. Records have not been submitted to support additional units. Based on this information, we decided that Medicare rules for coverage of an additional 20 units of propofol have not been met. Therefore, we decided that the Plan does not have to pay for an additional 20 units of propofol (J2704) provided on June 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond of an inlay (D2910) provided on April 29, 2021.
You asked the Plan to pay for the re-cement or re-bond of an inlay. You say that you feel this service save the Plan a lot of money by not having to place a crown on the tooth. You also say that the cost of a crown would have been much greater. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond of an inlay (D2910) provided on April 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 12, 
2021, through May 26, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the service should be 
covered. The Plan denied your request. The Plan says the cost share 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 $325 
copayment per days one through five for inpatient hospital care.  
 
You have been asked to pay a $325 copayment per days one through five for the inpatient hospital care. This 
service falls within the inpatient hospital care 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 inpatient hospital care provided on May 12, 2021, through May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the laboratory services rendered on
December 12, 2020.
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges.
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). The enrollee's contract with the Plan clearly says that enrollees
must pay a 5% coinsurance for in-network Medicare-covered lab services.
Review of the file shows that the enrollee received laboratory services on December 12, 2020. The enrollee has
been asked to pay a 5% coinsurance for these services. These services fall within the in-network Medicare-covered
lab services benefit category. This means that the enrollee has been asked to pay the correct amount
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the
laboratory services rendered on December 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental procedure (D9999) and complete denture repair (D5512), provided on December 16, 2020

You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says the services are not listed in the Plan's benefit chart.

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. Specifically, the services obtained are not listed in the Plan's benefit chart. This means the services are not covered benefits. Therefore, we decided that the Plan does not have to pay for the dental procedure (D9999) and complete denture repair (D5512), provided on December 16, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 64421 and 64420 provided on November 13, 2020.
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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. We find that CPT codes 64421 and 64420 are not supported in the medical record. Specifically, code 33210 (insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter) was also billed on this claim. National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 64421, 64420, and 33210. This PTP edit has a modifier indicator of 0, which indicates there are no modifiers that are allowed with this PTP code pair. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 64421 and 64420 provided on November 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the pontics and retainer crowns provided on March 17,
2021.
You asked the Plan to pay more for the pontics and retainer crowns. You say that you needed a bridge and were
informed insurance would cover the cost. You say that you would not have gotten the bridge if you knew it was
$900 and you don't think you should pay anything. The Plan denied your request. The Plan says the claim was
processed correctly as the annual maximum of $2,500 was met on this claim.
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, you also have a maximum benefit of
$2,500 annually for covered supplemental dental services. The Plan paid $2,415 toward the dental services
received on March 17, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have
to pay more for the pontics and retainer crowns provided on March 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis (74177) provided on April 26, 2021.
You asked the Plan to waive the copayment for a CT scan of the abdomen and pelvis. You say that Medicare needs to pay more because the copayment you have been charged is excessive. 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 $300 copayment for Medicare-covered advanced imaging or nuclear medicine services. You have been asked to pay a $300 copayment for a CT scan of the abdomen and pelvis. A CT scan of the
abdomen and pelvis 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 a CT scan of the abdomen and pelvis (74177) provided on April 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray (71045) provided on March 24, 2021.
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says the services were billed
incorrectly.
The Plan must follow Medicare rules. Medicare rules say that except for the therapy services, physician's
professional services and services of certain nonphysician providers listed below are excluded from Part A PPS
payment and the requirement for consolidated billing, and must be billed separately.
We looked at the file and Medicare rules. In this case code 71045 was billed without modifier -26. This code
must be billed with the -26 modifier to indicate that this was the professional component. Only the professional
component is payable in this case. Based on this information, we decided that Medicare rules for coverage of
the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray (71045)
provided on March 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on April 9, 2021.
You asked the Plan to pay for the services provided. You say that the services were denied without review of the medical records. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services.
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 97110 is Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record.
The records show that the enrollee received home health physical therapy services. The billed code does not precisely describe the services that were provided. Services should be billed with the most comprehensive code that reflects the services performed. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on April 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the fibromyalgia genetic testing provided on March 2, 2021.
You asked the Plan to pay for the testing services. You say that the enrollee can possibly participate in a clinical trial with a positive test result. The Plan denied your request. The Plan says predictive screening testing is not a Medicare benefit.
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 testing services at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the fibromyalgia genetic testing provided on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the allergy injections provided on February 23, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the allergy injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 allergy injections provided on February 23, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement provided on March 4, 2021 by an out-of-network provider.
You asked the Plan to pay for debridement, subcutaneous tissue (11042). You say that the services were provided prior to obtaining authorization to avoid delay in care which could result in wound complications. The Plan denied your request. The Plan says prior authorization was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for debridement provided on March 4, 2021 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental implant (D6010), provided on June 16, 2021.
You asked the Plan to pre-approve the dental implant. You say that the service was medically necessary. The
Plan denied your request. The Plan says this service is not covered under the Plan's 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, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the
dental implant (D6010), provided on June 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a session of 4 transforaminal epidural treatments (64483x2, 64484x2).

You asked the Plan to pre-approve transforaminal epidurals. You say that you are in extreme pain and the requested procedure is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that no more than two transforaminal injections may be performed at a single setting. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transforaminal epidurals have not been met. Specifically, the request is for greater than two transforaminal injections. Therefore, we decided that the Plan does not have to pre-approve a session of 4 transforaminal epidural treatments (64483x2, 64484x2).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 11 additional physical therapy visits.
You asked the Plan to pre-approve 11 additional physical therapy visits. You say that the enrollee has continued to have lingering limitations in range of motion and strength. You say that the documentation supports additional visits would be beneficial to the patient. 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 11 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 enrollee has had prior therapy and has been instructed in a home exercise program. Our reviewer says that he can continue to work on range of motion through the independent home exercise program and 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 11 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 11 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on November 10, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is covered when specific criteria are met. 

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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has rheumatoid arthritis and chronic knee and back pain. He is prescribed oxycodone and non-steroidal anti-inflammatory drugs (NSAIDs) for his pain. Urine drug screening showed positive THC along with opioids. Confirmation drug testing was requested. Only confirmation of the THC would be needed here. Multiple other drug classes were tested definitively which were not applicable to this case. The comprehensive drug testing panel was not 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing rendered on November 10, 2020.