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

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapist on May 11, 2020. 
 
You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate if services are not available from preferred providers. 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 services of an occupational therapist billed as 
services incident to a physician/non-physician practitioner's service must meet all incident requirements.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner. As such, occupational therapy services cannot be paid incident to this provider's professional 
services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided 
by an occupational therapist on May 11, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on April 7, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there was no 
documentation of consultation with the attending or primary care physician in the patient's medical record 
 
The Plan must follow Medicare rules. Medicare rules say that the CP must attempt to consult with the patient's 
physician within a reasonable time after receiving the consent. If the CP's attempts to consult directly with the 
physician are not successful, the CP must notify the physician within a reasonable time that he or she is 
furnishing services to the patient.  
 
We looked at the file and Medicare rules. The records provided do not show that the CP consulted the 
enrollee's PCP/attending. The claim form also does not list a referring physician. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the outpatient mental health services provided on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical therapy services provided on April 14, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the medical therapy services. You say that these services were medically reasonable and necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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 medical therapy services provided on April 14, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950 x 2), retainer crowns (D6740 x 2),
pontic (D6245), and extraction (D7210), provided on March 18, 2021.
You asked the Plan to pay for the dental services. You say that the claim was denied because the provider was
out of network. You say that the provider called to make sure the claim would be covered before beginning any
work. You also say that the dental rider clearly states that you have the freedom to see any dentist you choose.
The Plan denied your request. The Plan says the dental services you received are not listed as covered dental
services. The Plan says that you were not enrolled in the optional supplemental dental rider on the date of
service in this case. The Plan also says
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 core build up, retainer crowns,
pontic, and extraction are not among those covered under this benefit. Additionally, the record shows that the
optional supplemental dental rider was not effective until April 1, 2021. Therefore, we decided that the Plan
does not have to pay for the core build up (D2950 x 2), retainer crowns (D6740 x 2), pontic (D6245), and
extraction (D7210), provided on March 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational
therapist on March 5, 2021.
You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay noncontracted
providers at the preferred provider rate if services are not available from preferred providers. 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 services of an occupational therapist billed as
services incident to a physician/non-physician practitioner's service must meet all incident requirements.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse
practitioner. As such, occupational therapy services cannot be paid incident to this provider's professional
services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided
by an occupational therapist on March 5, 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 is not medically necessary.
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 there is no need for physician supervision 3 times per week (at a minimum) for the
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented skilled nursing needs. While you may benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity setting. 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.
You asked the Plan to pre-approve IRF care. You say that you do not currently have strength to be home on your own. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been 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 that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic (D6245), occlusal guard (D9944), and crown (D6740), provided on April 27, 2021, and June 10, 2021.
You asked the Plan to pay for the pontic, occlusal guard, and crown. You say that the services should be covered. The Plan denied your request. The Plan says these are not 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, 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 pontic (D6245), occlusal guard (D9944), and crown (D6740), provided on April 27, 2021, and June 10, 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 is not medically
necessary.
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 there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the
current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to
daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of
therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no
documented skilled nursing needs. While the enrollee may benefit from physical therapy and occupational
therapy, the rehabilitation needs can be safely met in an alternate and lower intensity setting.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest you had on February 18, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you believe this copayment is too high. 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 $100 copayment for diagnostic radiology services. You have been asked to pay a $100 copayment for the CT scan. The CT scan falls within the diagnostic radiology 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 computed tomography (CT) scan of the chest you had on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by an opt out provider on February 18, 2021.
You asked the Plan to pay for the dental services. You say that the Plan approved claims with this provider in 2018, 2019 and 2020. You say that the closest approved dentist is over 15 miles away and you want your current provider to be approved. The Plan denied your request. The Plan says payment cannot be issued for services from a provider that has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.
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. Therefore, we decided that the Plan does not have to pay for the dental services provided by an opt out provider on February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on March 5, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple code. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more toward the additional intraoral x-ray, limited oral
evaluation and endodontic therapy provided on June 9, 2021.
You asked the Plan to pay more toward the additional intraoral x-ray, limited oral evaluation and endodontic
therapy. You say that he took x-rays to properly diagnose the problem. You say that the decision to deny the
costs of a necessary procedure should be re-evaluated. The Plan denied your request. The Plan says only one
intraoral x-ray is covered per year and the limited oral evaluation and endodontic therapy remain denied as
non-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, you also have a maximum benefit of
one intraoral x-ray per calendar year. The Plan paid for one intraoral x-ray provided on June 9, 2021, which
exhausted your benefit. The limited oral evaluation and endodontic therapy remain denied as non-covered
benefits. Therefore, we decided that the Plan does not have to pay more toward the additional intraoral x-ray,
limited oral evaluation and endodontic therapy provided on June 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a heart rhythm symptom-related tracing of 24-hour electrocardiogram (EKG) monitoring up to 30 days (93270) rendered on March 24, 2021.
You asked the Plan to waive the copayment for a heart rhythm symptom-related tracing of 24-hour electrocardiogram (EKG) monitoring up to 30 days. You say that the Plan paid for the same service by a second provider. You also say that you want the provider for this appeal to cancel the invoice sent to you. The Plan denied your request. The Plan says you were charged the correct cost sharing 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). The record shows the invoice from the other provider that was already paid was for the monitoring services of the EKG. Your contract with the Plan clearly says that you must pay a $25 copayment for Medicare-covered non-radiological diagnostic services, including EKG's.
You have been asked to pay a $25 copayment for a heart rhythm symptom-related tracing of 24-hour electrocardiogram (EKG) monitoring up to 30 days (93270). A heart rhythm symptom-related tracing of 24-hour electrocardiogram (EKG) monitoring up to 30 days (93270) 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 heart rhythm symptom-related tracing of 24-hour electrocardiogram (EKG) monitoring up to 30 days (93270) rendered on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth originating site fee (Q3014) provided on
August 13, 2021, by an OON provider.
You asked the Plan to pay for the telehealth services. You say that the enrollee had a televisit with the primary
care physician which was needed for medication refill. This is the facility fee for originating facility. You are
asking for reconsideration and payment for these services. The Plan denied your request. The Plan says
enrollee's must receive their medical services from an in-network provider with the exception being urgent or
emergent services. Non-emergent services with non-contracted providers require prior authorization before
services being rendered.
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 telehealth originating site fee (Q3014)
provided on August 13, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on March 1, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that last year you were seen at an out-of-network provider, and have been referred to a participating provider. You also say that the in-network provider needed to perform a complete evaluation and diagnostic x-rays, and you would like these services to be covered. The Plan denied your request. The Plan says you have exceeded the frequency limits set in the subscriber agreement for these 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, comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on May 22, 2020, and a complete series of intraoral x-rays (D0210) on July 31, 2020, and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on March 1, 2021.