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

We decided that the Plan does not have to pay for an injection beneath the skin or into muscle for therapy, diagnosis, or prevention (96372) provided on October 4, 2019 to October 18, 2019 by out of network provider. 
 
You asked the Plan to pay for an injection beneath the skin or into muscle for therapy, diagnosis, or prevention. You say that you originally saw your physician on May 2, 2019 and the claim paid with no issues. You have established a relationship with this doctor and the treatment is working for you. You do not want to stop this treatment. You want this claim and future claims to be paid for treatment of your condition. The Plan denied your request. The Plan says they cover all medical services that are medically necessary, are listed in the plan's Medical Benefits Chart, and are obtained consistent with plan rules. You are responsible for paying the full cost of services that aren't covered by our plan, either because they are not plan covered services, or they were obtained out-of-network and 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 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 injection beneath the skin or into muscle for therapy, diagnosis, or prevention (96372) provided on October 4, 2019 to October 18, 2019 by out of network provider.
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 December 28, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 28, 2018.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by out of network provider
You asked the Plan to pre-approve physical therapy. You say that you would like pre-authorization for hand therapy. The Plan denied your request. The Plan says 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 pre-approve 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by out of network provider
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve PET scan of the brain for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that it is not known how this test will change treatment.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found while the NIA guidelines suggest a decline in cognitive functions over a 6 month period to qualify for PET imaging the clinical history and MRI findings of cerebellar atrophy indicate that the differential diagnosis of Lewy Body Dementia for which drug therapy is appropriate versus MSA for which no therapy is available are valid considerations. The best imaging test to differentiate between the two would be PET imaging. The ramifications are obvious - prescription drug therapy versus no therapy. 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 scan have been met. Therefore, we decided that the Plan has to pre-approve PET scan of the brain for the enrollee.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray provided on January 20, 2019.You asked the Plan to pay forthe x-ray. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services must be billed to the enrollee's primary carrier first.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the x-ray until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay forthe x-ray provided on January 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for determination of refractive state (CPT Code 92015) on September 12, 2019.
You asked the Plan to pay for the services. You say that you were seen on a yearly routine visit and during the course of examination you had a vision refraction. You state you assumed this was part of a routine visit since you do have a problem with your retina. The Plan denied your request. The Plan says this is not routine vision care.
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. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the services have not been met. Refractive services are not covered under your benefit plan unless rendered by an EyeQuest Routine Vision Care Provider found in the Routine Vision Care section of the Plan's Provider Directory. However, since some providers are contracted with both your Plan and EyeQuest, please do not pay this charge until you are billed. If your particular provider is contracted with both then the provider is expected to bill EyeQuest for the charge and not you. Therefore, we decided that the Plan does not have to pay for determination of refractive state (CPT Code 92015) on September 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests and consultation provided on September 6, 2019.
You asked the Plan to pay for the pulp vitality tests and consultation. You say that you called the Plan prior to having the services rendered and went to the providers that were recommended by the Plan, with nothing accomplished by any of them. The Plan denied your request. The Plan says this provider is not a part of the Plan's dental network. The Plan also says that there is no documentation that you or the provider contacted the Plan to confirm coverage prior to the services being rendered.
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 out-of-network. Therefore, we decided that the Plan does not have to pay for the pulp vitality tests and consultation provided on September 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for determination of refractive state (CPT Code 92015) on October 16, 2019.
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says a call was made to the provider office and you are only being charged for your $45 copayment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received determination of refractive state (CPT Code 92015) on October 16, 2019. Even though this service is denied, the Plan verified that you are only being charged a $45 copayment for the services you received on October 16, 2019. 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 pay for determination of refractive state (CPT Code 92015) on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, each additional intraoral periapical x-ray, core buildup, including any pins when required, and panoramic x-ray provided on September 4, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation, additional intraoral periapical x-ray, core buildup, and panoramic x-ray. You say that you had an abscessed tooth which was affecting you to the point that you were unable to chew well. The Plan denied your request. The Plan says this provider is out-of-network with your plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, each additional intraoral periapical x-ray, core buildup, including any pins when required, and panoramic x-ray provided on September 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for x-rays provided on October 7, 2019.
You asked the Plan to waive the copayment for x-rays. You say that you think the office visit copayment should cover the x-ray as well. The Plan denied your request. The Plan says the correct copayment has been applied to the service that was 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 you must pay a $55 copayment for outpatient diagnostic tests/x-ray. You have been asked to pay a $55 copayment for x-rays. An x-rays falls within the outpatient diagnostic tests/x-ray 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 x-rays provided on October 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Colchicine for the enrollee.
You asked the Plan to pre-approve Colchicine. You say that the enrollee has acute gouty arthritis. The Plan denied your request. The Plan says that this medication is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Colchicine for the enrollee.
Benefits for Colchicine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851), lumbar-sacral orthosis (L0650) and suspension sleeve (L2397) provided to the enrollee on August 1, 2019.
You asked the Plan to pay for the orthoses and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
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 pay for the orthoses and sleeve. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeve ordered.
Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 orthoses and sleeve have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851), lumbar-sacral orthosis (L0650) and suspension sleeve (L2397) provided to the enrollee on August 1, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 2,2019 to July 16, 2019 by an out-of-network provider.You asked the Plan to pay forthese 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, outof 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 forthe medical services provided on July 2, 2019 to July 16, 2019 by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computer-assisted surgical navigational procedure for musculoskeletal procedures (20985).
You asked the Plan to pre-approve a computer-assisted surgical navigational procedure for musculoskeletal procedures. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says per Medicare guidance; this service is listed as a non-covered service.
The Plan must follow Medicare rules. Medicare rules say that that plans must pay for a medical service or item if regular Medicare would pay for it in this case. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a computer-assisted surgical navigational procedure for musculoskeletal procedures have not been met. Specifically, the computer-assisted surgical service (20985) is listed as a non-covered service in Local Coverage Article: Billing and Coding: Noncovered Services (A57743). Therefore, we decided that the Plan does not have to pre-approve a computer-assisted surgical navigational procedure for musculoskeletal procedures (20985).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablations at L4-L5 and L5-S1.
You asked the Plan to pre-approve radiofrequency ablations at L4-L5 and L5-S1. You say that the requested radiofrequency ablations are medically necessary. The Plan denied your request. The Plan says the requested radiofrequency ablations do not meet criteria.
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 radiofrequency ablations at L4-L5 and L5-S1. Our reviewer says that the requested radiofrequency ablations do not meet criteria. Our physician reviewer found the enrollee has chronic low back pain. He had 2 successful diagnostic medial branch blocks and then had radiofrequency ablation (RFA). His back pain continues. He appears to have developed pain/numbness in his foot. The request is for repeat RFA. Based on the documentation provided, the enrollee did not achieve significant sustained pain relief from the RFA. The request to repeat it is not medically reasonable or 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 radiofrequency ablations at L4-L5 and L5-S1 have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablations at L4-L5 and L5-S1.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient specialist visit (99205) provided on July 19, 2019.
You asked the Plan to waive the copayment for the outpatient specialist visit. You say that you paid the copayment for surgery on the same date of service, so the $50 copayment should not apply. The Plan denied your request. The Plan says the copayments for physician services are noted in the EOC and this copayment 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 $50 copayment for Physician/Practitioner services. You have been asked to pay a $50 copayment for the outpatient specialist visit. The outpatient specialist visit falls within the Physician/Practitioner 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 an outpatient specialist visit (99205) provided on July 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation provided on September 30, 2019.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that before this provider performed the examination and x-ray, they contacted your plan and confirmed that the procedures were covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that they confirmed with the provider's office that you were told this service would not be covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation provided on September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for grab bars received on August 24, 2019.
You asked the Plan to pay for the bars. You say that this is necessary for safety. The Plan denied your request. The Plan says this is not a covered benefit.
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 pay for grab bars received on August 24, 2019.