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

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on December 16, 2020.
You asked the Plan to pay for the laboratory test. You say that you are a specialized laboratory that performs drug monitoring in good faith at the request of the ordering physician. You say that you attached the signed requisition form and lab report, and payment should be allowed. 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 laboratory test provided by an out-of-network provider on December 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on October 28, 2020.
You asked the Plan to waive the copayment for arthrocentesis. You say that the Plan was supposed to pay 80% coinsurance but instead only paid 45% coinsurance. 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 a $350 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. You have been asked to pay the allowed amount of $271.55, which is less than the $350 copayment for arthrocentesis. Arthrocentesis falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 arthrocentesis provided on October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for eye exams provided on January 6, 2021, and January 8, 2021.
You asked the Plan to waive the copayments for eye exams. You say that you disagree with the charges because the visits are related to a cataract surgery. 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 a $20 copayment for medical eye exams for vision care. The medical records show that you received an eye exam on January 6, 2021. Therefore, you are responsible to pay the $20 copayment. You have been asked to pay the total copayment amount of $40 for eye exams. Eye exams fall within the vision 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 copayments for eye exams provided on January 6, 2021, and January 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a life alert system (A9280).
You asked the Plan to pre-approve the life alert system. You say that the life alert system is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
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 a life alert system (A9280).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 19, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 services at issue in this appeal. 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 the services provided by an out-of-network provider on November 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider December 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says 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 had network providers available who could have provided the services at issue in this appeal. 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 the services provided by an out-of-network provider December 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral genicular nerve radiofrequency ablation (RFA) procedure.
You asked the Plan to pre-approve bilateral genicular nerve RFA procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not met.
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 bilateral genicular nerve RFA procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure. It is the subject of on-going clinical trials. Therefore, the request is considered not medically reasonable and 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 bilateral genicular nerve RFA procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral genicular nerve radiofrequency ablation (RFA) procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit rendered on December 15, 2020.

You asked the Plan to waive the copayment for these services. You say that you believe this is copayment stacking. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for each covered visit or consultation in an outpatient location with a specialist.

Review of the file shows that you received specialist services on December 15, 2020. You have been asked to pay a $15 copayment for these services. These services fall within the covered visit or consultation in an outpatient location with a specialist 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 specialist office visit rendered on December 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from December 5, 2020, through December 14, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 each time you are admitted to an acute care hospital, you must pay $275 per day for days 1-5 and $0 after day 5. You have been asked to pay $1375 ($275 x 5 days) for the inpatient hospital care provided. 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 inpatient hospital care provided from December 5, 2020, through December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and two amalgams provided on October 8, 2020, and October 27, 2020.

You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and amalgams. You say that you believe these services should be covered. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective February 10, 2016, to February 10, 2022. The Plan also says that charges incurred by Medicare opt out providers will not be reimbursed.

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 covered when they are received by a Medicare opt out provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and two amalgams provided on October 8, 2020, and October 27, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration (99601), home infusion therapy, implanted pump pain management infusion (S9328), and home infusion therapy, anti-spasmotic therapy (S9363) provided on September 21, 2020.

You asked the Plan to pay for the home infusion/specialty drug administration, implanted pump pain management infusion, and anti-spasmotic therapy. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the billed code is not valid for Medicare purposes and is not covered.

The Plan must follow Medicare rules. Medicare rules say that procedure codes 99601, S9328, and S9363 are not valid for Medicare purposes and are not payable. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home infusion/specialty drug administration, implanted pump pain management infusion, and anti-spasmotic therapy have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug administration (99601), home infusion therapy, implanted pump pain management infusion (S9328), and home infusion therapy, anti-spasmotic therapy (S9363) provided on September 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D4263) and gingival flap procedure (D4241) provided on April 28, 2018.

You asked the Plan to pay for the dental procedures. You say that this should be covered as a surgical or medical procedure. The Plan denied your request. The Plan says the procedures provided are dental services and were provided by a dental professional. The Plan will cover up to $100 per year to cover non-Medicare preventative dental services. The Plan issued a $100 payment for these services, however the total cost for the services exceeded the maximum $100 allowance for the dental benefit. You are responsible for the remaining cost.

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 Plan will pay up to $100 per year for dental services. 

The services at issue are dental in nature because they involve the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. These services are not covered by Medicare, but the Plan offers a supplemental dental benefit for additional coverage. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services exceeded the benefit maximum of $100. Therefore, we decided that the Plan does not have to pay for the bone replacement graft (D4263) and gingival flap procedure (D4241) provided on April 28, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic massage provided on November 20, 2020.

You asked the Plan to pay for the therapeutic massage. The Plan denied your request. The Plan says that the Plan covers 6 visits only and the 7th visit is not covered under the Plan's benefit.

The rules say that Medicare does not cover the services of a naturopath. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers Naturopathic services with a maximum number of 6 visits every year. Therapeutic massage is covered under the Naturopathic services. 

We looked at the file and the Plan's rules. The file shows that the Plan covers a maximum number of 6 visits per year for Naturopathic services. Therapeutic massage is covered under the Naturopathic services benefit. The Plan has paid the maximum number of 6 visits. Therefore, we decided that the Plan does not have to pay for therapeutic massage provided on November 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for WATS 3D testing (88104, 88305, 88312, 88361) provided on August 17, 2020.

You asked the Plan to pay for WATS 3D testing. You say that this was medically necessary. The Plan denied your request. The Plan says this cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that when a hospital obtains laboratory tests for outpatients under arrangements with clinical laboratories or other hospital laboratories, only the hospital can bill for the arranged services. 

We looked at the file and Medicare rules. The record shows that the laboratory services at issue were provided to a hospital outpatient and were billed with Place of Service 22, outpatient hospital. These services must therefore be billed by the hospital. Based on this information, we decided that Medicare rules for coverage of WATS 3D testing have not been met. Therefore, we decided that the Plan does not have to pay for WATS 3D testing (88104, 88305, 88312, 88361) provided on August 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on November 24, 2020 by an out of network (OON) provider.

You asked the Plan to pay for diagnostic radiology 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 participating 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 diagnostic radiology services provided on November 24, 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 blood glucose test strips and solution provided from June 17, 2020, to September 18, 2020.

You asked the Plan to pay for the blood glucose test strips (A4253) and solution (A4256). You say that the Plan should pay this claim.The Plan denied your request. The Plan says medical records do not document the frequency of insulin.


The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. There is no proof of delivery or medical records in the case file.The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay for the blood glucose test strips and solution provided from June 17, 2020, to September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on November 11, 2020 and November 13, 2020 by an out of network provider.
You asked the Plan to pay for the chiropractic services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request 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 had network providers available who could have provided the services at issue in this appeal. 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 the chiropractic services provided on November 11, 2020 and November 13, 2020 by an out of network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 services. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found you do not have documented skilled occupational therapy needs. Your activities of daily living needs appear to be custodial. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on December 21, 2020.

You asked the Plan to pay for the paramedic intercept services. You say that this service was for a lifesaving emergency treatment. The Plan denied your request. The Plan says this item is not a covered benefit.

The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York.

The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on December 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on October 29, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on October 29, 2020.