Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia and injection provided by an out-of-network provider on November 19, 2020.
You asked the Plan to pay for the anesthesia and injection. You say that the patient had no knowledge the surgeon utilized an out-of-network anesthesiologist. You say that the claim should be processed in-network. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.
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 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 anesthesia and injection provided by an out-of-network provider on November 19, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy (CPT code 90834) provided to the enrollee on December 17, 2020.

You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.

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 psychotherapy (CPT code 90834) provided to the enrollee on December 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3330) provided on November 16, 2020.
You asked the Plan to pay for the dental service. You say that this provider is listed in the in network provider directory. You say that the specific dentists were not listed. You say that you followed the rules. You also say that this service should be covered. The Plan denied your request. The Plan says the provider in this case is not listed as a covered service. The Plan also says that dental services performed 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 and the service is listed as covered, dental services performed out of network are not covered. Additionally, there is no record that you contacted
the dental plan prior to the date of service to verify the providers network status. Therefore, we decided that the Plan does not have to pay for the root canal (D3330) provided on November 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for radiation therapy services (45378, 77412, 77331, 77290) provided January 11, 2021 to February 4, 2021.
You asked the Plan to waive the copayments for the radiation therapy services. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct copayments have been 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 $60 per visit copayment for Radiation Therapy.
You have been asked to pay a $60 per visit copayment for 19 radiation treatments, for a total of $1,140. 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 copayments for radiation therapy services (45378, 77412, 77331, 77290) provided January 11, 2021 to February 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility services.
You asked the Plan to pre-approve the Skilled Nursing Facility services. You say that the services are
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 Skilled Nursing Facility services.
Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does
not have any parental medication; complex wound care or nutrition given via a feeding tube. He is medically
stable without any acute exacerbation of chronic medical problems. His physical function is at or near his
baseline and he can receive services at a lower level of care.
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 Skilled Nursing Facility services have not been met. Therefore, we decided
that the Plan does not have to pre-approve Skilled Nursing Facility services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient behavioral health services provided on
November 27, 2020 to December 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the inpatient services. You say that please process this as a clinical appeal for
authorization. The enrollee was admitted to your facility involuntarily under the Baker Act by emergency room
physician due to psychosis. 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 inpatient behavioral health services provided
on November 27, 2020 to December 1, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88173, 88302) provided on December 24, 2020 by an out of network (OON) provider.

You asked the Plan to pay for OON laboratory 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 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 laboratory services (88173, 88302) provided on December 24, 2020 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 nutria-pharmaceutical injections and treatment with a Sanexas device reported on September 1, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed 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. In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using
standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services provided on August 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for ophthalmology services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available for these services.
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 ophthalmology services provided on August 11, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator rendered on September 19,
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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS
suppliers are required to maintain proof of delivery.
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 neuromuscular stimulator rendered on September 19,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable control system.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says your
limb strength and function are adequate to control the power options using their own switches.
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered
under certain medical indications.
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 requested services. Our physician
reviewer found that you have 4 out of 5 upper limb strength. You are independent with eating and grooming.
The strength and function in your upper extremities, with the ability to feed yourself, indicates that you can
control any power options through their own individual switches.
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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve an expandable control system.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy visit provided on September 10, 2020, by
an OON provider.
You asked the Plan to pay for the psychotherapy visit. You say that the service was medically necessary. The
Plan denied your request. The Plan says no prior authorization was obtained.
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
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 psychotherapy visit provided on September 10,
2020n by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit for the evaluation and management of a new patient (CPT code 99327) provided to the enrollee on November 2, 2020, by an out-of-network provider.
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 this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 domiciliary or rest home visit for the evaluation and management of a new patient (CPT code 99327) provided to the enrollee on November 2, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on February 12, 2021.
You asked the Plan to pay for the ophthalmological services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for ophthalmological services provided on February 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the vascular embolization or occlusion services coded 37242 provided on December 18, 2020.
You asked the Plan to pay for the vascular embolization or occlusion services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 37242 is vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary
to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms). We find that CPT code 37242 is not supported in the medical record. Specifically, the operative report did not include documentation of a vascular embolization or arterial occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention, to treat a condition other than hemorrhage or tumor (congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms); therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the vascular embolization or occlusion services have not been met. Therefore, we decided that the Plan does not have to pay for the vascular embolization or occlusion services coded 37242 provided on December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on March 3, 2020.
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says prior authorization was not obtained.
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 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 office visit provided by an out-of-network provider on March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on July 25, 2019.
You asked the Plan to pay for the dental services. You say that dentures were needed for breathing, eating, and
talking. The Plan denied your request. The Plan says the services 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.
The file shows that periodontal scaling and root planning, surgical extractions, alveoloplasty, fillings, and
sedation were provided. Although the Plan offers a dental benefit in excess of Medicare coverage, these
services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the dental services provided on July 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lenses you received on January 17, 2020.
You asked the Plan to pay for the lenses. The Plan denied your request. The Plan says this is not a covered benefit.
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's routine visit care benefit covers one routine eye exam per year. We looked at the file and the Plan's rules. Progressive lenses are not covered by Medicare or the Plan. Based on this information, we decided that the Plan's rules for coverage of the lenses have not been met. Therefore, we decided that the Plan does not have to pay for the progressive lenses you received on January 17, 2020
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay foran astigmatism-correcting function of an IOLprovided on December 7, 2020.You asked the Plan to pay forthe astigmatism-correcting function ofanIOL. The Plan denied your request. The Plan says this service is not covered by original Medicare.The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL.Therefore, we decided that the Plan does not have to pay foran astigmatism-correcting function ofanintraocular lens IOL providedon December 7,2020.