Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided on November 5, 2019 to December 1, 2019 by an out of network (OON) provider.You asked the Plan to pay for OON home health services. You say that these services were medically necessary.The Plan denied your request. The Plan says these services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the under the Point-of-Service benefit, your provider may need to obtain approval in advance for those services marked with an asterisk (*) in the Medical Benefits Chart, such as home health agency services.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. 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 home health services provided on November 5, 2019 to December 1, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 28, 2019 by an out of network (OON) provider.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 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 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. 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 services provided on October 28, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an out of network office visit provided to the enrollee on November 19, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services 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 these services. Therefore, we decided that the Plan does not have to pay for an out of network office visit provided to the enrollee on November 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services
provided from November 1, 2019 to November 19, 2019.
You asked the Plan to waive the copayment for the SNF services. The Plan denied your request. The Plan says
that cost-sharing is a contractual obligation of the plan and cannot be waived.
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 $160
copayment for each day for days 21 to 62 of SNF care.
You have been asked to pay a $160 copayment for the SNF services. The SNF services fall within the days 21
to 62 of SNF care benefit category. The file indicates you were in a SNF for 28 days. You have been asked to
pay a copayment of $160 for eight days. 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 skilled
nursing facility (SNF) services provided from November 1, 2019 to November 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 77080 provided on December 3, 2019.
You asked the Plan to pay for CPT code 77080. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a screening bone densitometry test, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for CPT code 77080 provided on December 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on September 23, 2019.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 testing is not covered.The Plan must follow Medicare rules. The rules say that GeneSight testing is covered for enrollees who meet specific criteria with at least one prior neuropsychiatric medication failure. We looked at the file and Medicare rules. The file shows that the enrollee does not have at least one prior neuropsychiatric medication failure. 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 GeneSight Psychotropic Assay rendered on September 23, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health care provided out of network on December 77, 2019.You asked the Plan to pay forthis service. You say that you have seen this provider a long time and the Plan should cover this visit.The Plan denied your request. The Plan says you did not have a referral from your primary care physician and prior authorization for out of network outpatient mental health care.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-approvedcare.The contract with the Plan specifically states outpatient mental health care requires both a referral and prior authorization. The requested provider is not a network provider with the Plan. The Plan has network providers available who can providethe services at issue in this appeal. The Plan did not pre-approve this service and you did not have a referral. 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 foroutpatient mental health care provided out of network on December 77, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on November 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that the member provided a traditional Medicare card. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the primary care provider did not refer the member.
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 has network providers available who can provide 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 an office visit provided on November 14, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
January 25, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you insisted that you
did not want to be taken to the hospital after your fall. You say you should not be responsible for the
copayment. The Plan denied your request. The Plan says you have been 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). Your contract with the Plan clearly says that you must pay a $90
copayment for Medicare-covered emergency room visits.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency 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 the
emergency room visit provided on January 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on January 6, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you do not understand why you have to pay such a huge amount for a scan that was necessary. The Plan denied your request. The Plan says you have been 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). Your contract with the Plan clearly says that you must pay a $150 copayment for Medicare-covered diagnostic radiology services at a free-standing clinic. You have been asked to pay a $150 copayment for the CT scan. The CT scan 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 the CT scan provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the panoramic x-ray provided on January 28, 2020.
You asked the Plan to pay for the panoramic x-ray. You say that you did not know it was not time to receive
the x-ray. You also say that the provider did not advise you it was not time for the x-ray. The Plan denied your
request. The Plan says that panoramic x-rays are covered once every 36 months. The Plan also says that you
received a panoramic x-ray on June 21, 2017.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were referred for the panoramic x-ray by an in-network provider. This provider is a contract provider and
the enrollee could have reasonably believed that the provider would notify you if this service was not going to
be covered, and only render services that you were eligible for. The file does not show that the Plan provided
notice that the panoramic x-ray would not be covered. The contract does not clearly state that the benefit
limitation is 3 years to the day that the last procedure was rendered, and you could reasonably have believed
that you were eligible anytime in 2020 for another x-ray. Under Medicare rules, this means the panoramic x-ray
is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the panoramic x-ray
provided on January 28, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: 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 it is felt that the enrollee would benefit from an intensive therapy program.The Plan denied your request. The Plan says this member is not medically stable as the surgeon just documented the patient's incision may be infected and to continue the Rocephin. In addition, there must be documentation the member requires more intensiverehabilitation than may be obtained at a lower level of care which is not documented.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 member was admitted on 04/07/2020 with a right-sided empyema and pneumonia due to strep intermedius and underwent a thoracotomy with lung decortication on 04/14/2020. As of 04/26/2020 he was cachectic and weak appearing. His breath sounds had improved at the right base and were only minimally diminished. His chest tubes were dry without surrounding edema. There was mild edema at the right posterior chest incision with some normal skin bulging at the edges. He had scant serous drainage and the wound edges were not fully approximated medially. There was slight tenderness over the red area. He was able to move all extremities. There was 1+ leg edema. He had a sacrococcygeal wound that had been examined 4 days before with a thin layer of level of yellow slough without necrosis or foul smell.The member's medical conditions appear stable. There are no complex wound care needs. There are no unaddressed medical issues. He does not require medical oversight of his condition at an acute hospital level of care. The member is limited by pain and debility as well as the severity of his comorbid medical conditions. He would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network physician services provided on January 7, 2020.You asked the Plan to pay forthis service. You say that no one told you that you needed prior authorization.The Plan denied your request. The Plan says you did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan 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 has network providers available who can provide the services 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 these services.Therefore, we decided that the Plan does not have to pay for out of network physician services provided on January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on December 23, 2019.You asked the Plan to pay for foot orthotics. You say that you were told the orthotics would be covered.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pay for foot orthotics provided on December 23, 2019
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Cxbladder testing provided on November 22, 2019.
You asked the Plan to pay for Cxbladder testing. You say that you disagree with the Plan's denial and are requesting coverage. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test is not a covered benefit for the diagnoses listed and was performed for screening purposes.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for Cxbladder testing by an in-network provider. The file does not show that the plan provided notice that Cxbladder testing would not be covered. Under Medicare rules, this means Cxbladder testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for Cxbladder testing provided on November 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the ambulance transport and emergency room visit provided from October 8, 2019 to October 9, 2019.
You asked the Plan to waive the copays for the ambulance transport and emergency room visit. You say that The Plan denied your request. The Plan says that the claims processed 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 $40 copay for each Medicare-covered Ground Ambulance service and a $120 copay for Emergency care. You have been asked to pay a $40 copay for the ambulance transport and a $120 copay for the emergency room visit. The ambulance transport falls within the Medicare-covered Ground Ambulance service and emergency room visit falls within the Emergency 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 copays for the ambulance transport and emergency room visit provided from October 8, 2019 to October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on January 21, 2020.You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says services rendered by non-participating providers require prior authorization as outlined in the enrollees EOC.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 services at issue. We found noexception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a domiciliary, rest home visit provided on January 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a sleep study (95811) provided on August 27, 2019.
You asked the Plan to pay for a sleep study. You say that medical records have been submitted. The Plan denied your request. The Plan says records were not submitted for the correct date of service.
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 code 95811 is not supported in the medical record. Specifically, this code was billed for date of service August 27, 2019. The medical records submitted are not for this date of service, therefore the use of the code cannot be verified. Based on this information, we decided that Medicare rules for coverage of a sleep study have not been met. Therefore, we decided that the Plan does not have to pay for a sleep study (95811) provided on August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D033), the oral and face pictures (D0350), and the comprehensive oral evaluation (D0150) provided on January 6, 2020 by an out of network dentist.
You asked the Plan to pay for the dental services. You say that you were not advised that the provider was not in network with your plan. You say that you received a provider's list from the plan. You say that this office was listed The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says dental services that you receive out of network 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not covered when you receive them out of network. The record shows that the dentist office is listed in the Provider Manual, however, the specific provider that is listed at this location is not who you performed the dental services. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D033), the oral and face pictures (D0350), and the comprehensive oral evaluation (D0150) provided on January 6, 2020 by an out of network dentist.