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

We decided that the Plan does not have to pre-approve office visit services to be provided by an out-of-network (OON) provider who has opted out of the Medicare program.
You asked the Plan to pre-approve office visit services to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available to you that can provide the services you are requesting. Furthermore, the OON provider you are requesting has opted out of the Medicare program and is not eligible for payment for any services provided.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visit services to be provided by an out-of-network (OON) provider who has opted out of the Medicare program
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364) provided on September 23, 2021.
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you feel this service should be covered because your dentist told you it was necessary for the dental procedure. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364) provided on September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee osteoarthritis. Genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain. The services are therefore not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
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. The Plan denied your request. The Plan says the therapy records and the test scores show the enrollee is no longer making significant progress in function with skilled treatment at this time. Skilled treatment is not needed to maintain function. The enrollee can continue with the home program. More skilled treatment is not needed at this time.
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 on review of the limited available records; the enrollee does not meet Medicare coverage criteria for the requested additional physical therapy visits beyond the number received so far. The enrollee needs pain control and without that it is not expected that therapy will improve her mobility. There are no clinical details of the extent of her thigh pain to support the medical necessity for the therapy sessions. The documentation does not support coverage for additional therapy visits which are not medically necessary. The requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment safely and effectively, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exercise bike.
You asked the Plan to pre-approve an exercise bike. You say that you need this item. The Plan denied your request. The Plan says exercise equipment is noncovered as its primary purpose is not medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an exercise bike.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment without transport
(A0998-GY) provided on July 1, 2021.
You asked the Plan to pay for the ambulance response without transport. You say that this service was billed
with a valid code and should be paid. The Plan denied your request. The Plan says the ambulance benefit is a
transportation benefit. When no transport is provided, there is no payable service. Ambulance response and
treatment without transport (A0998) is excluded from coverage under Medicare.
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 1, 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 the ambulance response and treatment without
transport (A0998-GY) provided on July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the drive nitro duet transfer walker with seat for the
enrollee.

You asked the Plan to pre-approve the walker. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not show the features of this item that distinguish it from other available
alternatives or what medical outcome might occur if this item is approved.

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 walker. Our reviewer says that the
requested walker is not considered medically reasonable and necessary in this case. Our physician reviewer
found the case file does not contain clinical documentation that supports that a drive nitro duet transfer walker
with seat is medically reasonable and necessary for the enrollee in this case.

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 walker have not been met. Therefore, we decided that the Plan does not
have to pre-approve the drive nitro duet transfer walker with seat for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (CPT code 90837) provided to
the enrollee from May 3, 2019, through June 6, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says Medicare denies a claim for untimely filing if the receipt date applied to the claim
exceeds twelve (12) months or one (1) calendar year from the date the services were furnished.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service. The record shows that a claim for the
services was not filed until September 10, 2021. This means that more than one calendar year from the date of
service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the
psychotherapy services (CPT code 90837) provided to the enrollee from May 3, 2019, through June 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on
August 20, 2021.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you were told that the
charges would be fully covered but now you are receiving a bill with high 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 20%
coinsurance for DME and related supplies.
You received DME and related supplies on August 20, 2021. Therefore, you are responsible to pay your share
of the cost-sharing charges. The total allowed amount is $561.73 and 20% of that is $112.35.
You have been asked to pay the total coinsurance amount of $112.35 for DME and related supplies. DME and
related supplies fall within the DME and related 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 coinsurance for DME and related supplies provided on August 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (CPT code 99223) provided to the
enrollee on August 11, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says this service is not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the service have not been met. Review of the file shows that the
inpatient hospital service denied because this service is included in another service provided at the same time
and is not allowed separately. Therefore, we decided that the Plan does not have to pay for initial hospital care
(CPT code 99223) provided to the enrollee on August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you are wheelchair dependent and cannot practice good hygiene without this. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) provided July 13, 2021.

You asked the Plan to pay for the eye refraction. You say that you feel this service should be covered. The Plan denied your request. The Plan says this routine vision service was not provided by a routine vision provider and therefore is not covered.

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 a year when obtained through one of the Plan's third-party vision vendor's network providers. 

We looked at the file and the Plan's rules. In this case the eye refraction was not obtained from a provider who is part of the Plan's third-party vision vendor's network. 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 July 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an Automatic External Defibrillator (AED).
You asked. the Plan to waive the coinsurance for an AED. You say that you were never told the item was not covered. The Plan denied your request. The Plan says the proper coinsurance 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 20% coinsurance for Medicare covered durable medical equipment item. The monthly amount cost is $2931.45, and the total amount allowed in three months is $8,794.35. The monthly coinsurance amount is $586.29 ($2931.45 X 20% coinsurance), and the total amount allowed in three months is $1,758.87 ($586.29 X 3 months).
You have been asked to pay a 20% coinsurance for an Automatic External Defibrillator (AED). The AED falls within the Medicare covered Durable Medical Equipment (DME) and related 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 coinsurance for the AED.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
January 26, 2021 to February 6, 2021.
You asked the Plan to pay for home health services. You say that you would like reconsideration because these
services were rendered prior to the 5 day rule taking affect. The Plan denied your request. The Plan says the
claim started on January 26, 2021 and ended on February 6, 2021 and is subject to the Medicare guidelines for
calendar year 2021 as the start and end dates of the claim are both in 2021.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the
documentation submitted indicates that the RAP for these services was not submitted within 5 days of the
"from" date. Therefore, we decided that the Plan does not have to pay for the home health services provided to
the enrollee from January 26, 2021 to February 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on September 15, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 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 (99213) rendered by the out-of-network (OON) provider on
September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four alveoloplasties in conjunction with extractions (D7311 x4).
You asked the Plan to pre-approve the alveoloplasties. You say that you need to have the alveoloplasties with the extractions to help with the pain. 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. Therefore, we decided that the Plan does not have to pre-approve four alveoloplasties in conjunction with extractions (D7311 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite of three surfaces (D2393) and resin-based composite of four or more surfaces (D2394) provided on October 18, 2021.

You asked the Plan to pay for the resin-based composites. You say that these services were medically necessary because your old fillings were breaking and were unhealthy. The Plan denied your request. The Plan says these services are not covered 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 pay for the resin-based composite of three surfaces (D2393) and resin-based composite of four or more surfaces (D2394) provided on October 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the travel scooter rendered by the out-of-network (OON) provider on July 26, 2021.
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the item was 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 issue reimbursement 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 item at issue in this appeal. The Plan did not pre-approve the item at issue.
We found no exception that would require the Plan to issue reimbursement for this item. Therefore, we decided that the Plan does not have to issue reimbursement for the travel scooter rendered by the out-of-network (OON) provider on July 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a wheelchair (K0001) provided on August
19, 2021.
You asked the Plan to waive the coinsurance for the wheelchair. You say that the enrollee was not aware of the
wheelchair on their porch for a week and never wanted it. The Plan denied your request. The Plan says the
cost-sharing applied correctly based on the item provided even though the wheelchair was returned.
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 18% coinsurance for Durable medical equipment (DME) and related supplies.
The enrollee has been asked to pay a 18% coinsurance for a wheelchair ($44.04 x 18% = $7.92). Wheelchairs
fall within the Durable medical equipment (DME) and related supplies 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 a wheelchair (K0001) provided on August 19, 2021.