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

We decided that the Plan does not have to waive the copayments for specialist visits provided on August 22, 2019 and August 29, 2019.
You asked the Plan to waive the copayments for specialist visits. You say that you disagree with the out-of-network charges. 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 $65 copayment for out-of-network physician/practitioner services, including doctor's office visits. You had a specialist visit with an out-of-network provider on August 22, 2019. Therefore, you are responsible to pay the $65 copayment. You had a specialist visit with an out-of-network provider on August 29, 2019. Therefore, you are responsible to pay the $65 copayment. The total amount you owe is: $130.00. You have been asked to pay the total copayment amount of $130.00 for specialist visits. Specialist visits fall within the physician/practitioner services, including doctor's office visits 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 specialist visits provided on August 22, 2019 and August 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Visual Field Assessment Tech Support (CPT Code 0379T) provided on September 17, 2019.
You asked the Plan to pay for the services. You say that you were not advised the provider was out-of-network. The Plan denied your request. The Plan says 0379T is a temporary code lacking research to support improved medical outcomes.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. This service is not considered medically necessary. Therefore, we decided that the Plan does not have to pay for Visual Field Assessment Tech Support (CPT Code 0379T) provided on September 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ear mold/insert, not disposable, any type (V5264).
You asked the Plan to pre-approve the ear mold. You say that you have constant ear infections from water getting into your ears. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ear mold have not been met. This item is not covered under Medicare or the Health Plan. Therefore, we decided that the Plan does not have to pre-approve ear mold/insert, not disposable, any type (V5264).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on August 2, 2019.
You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the charges because the procedure was not completed. 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 $30 copayment for an X-ray. You have been asked to pay a $30 copayment for an X-ray. An X-ray 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 an X-ray provided on August 2, 2019.
We note your complaint that the procedure was not completed. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar traction unit.
You asked the Plan to pre-approve a lumbar traction unit. You say that your physical therapist recommended this item. The Plan denied your request. The Plan says records were not submitted to show this is medically necessary.
The Plan must follow Medicare rules. Medicare rules say that traction equipment is covered if patient has orthopedic impairment requiring traction equipment that prevents ambulation during the period of use. We looked at the file and Medicare rules. The file does not contain any medical records, so the medical necessity of this item cannot be established. Based on this information, we decided that Medicare rules for coverage of a lumbar traction unit have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar traction unit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oxygen concentrator and portable gaseous oxygen system provided on September 28, 2019 by out of network provider.
You asked the Plan to reimburse you for the oxygen concentrator and portable gaseous oxygen system. You say that you were out of area and a physician determined that you needed oxygen because of the high altitude. The Plan denied your request. The Plan says there are national options for oxygen equipment supplies in network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan does not have to reimburse you for oxygen equipment out-of-network. The requested provider in this case is not a network provider with the Plan. The Plan has 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 reimburse you for these items/services. Therefore, we decided that the Plan does not have to reimburse you for the oxygen concentrator and portable gaseous oxygen system provided on September 28, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the EPI (ExoDX prostate/Intelliscore) test provided to the enrollee on September 27, 2019.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is listed by the Medicare guidelines as being not medically necessary.
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 pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the enrollee was a 65 year old man who had a diagnosis of elevated PSA. The PSA results were not included in the record. No other clinical details were included in the record. Based on the paucity of submitted records, the enrollee does not meet the criteria for this testing. 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 pay for the EPI (ExoDX prostate/Intelliscore) test provided to the enrollee on September 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a white cane.
You asked the Plan to pre-approve a white cane. You say that because of your medical condition you need a white cane to avoid the risk of falling and other repercussions. The Plan denied your request. The Plan says neither Medicare nor the Plan cover white canes.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a white cane have not been met. Therefore, we decided that the Plan does not have to pre-approve a white cane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary for a diagnosis of hammer toes. 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 pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services provided on October 13, 2019.
You asked the Plan to waive the copayment for urgent care services. You say that you were told that there would be no copayment for the removal of your stitches. The Plan denied your request. The Plan says the correct copayment has been applied to this service.
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 urgently needed services/in-network. You have been asked to pay a $15 copayment for urgent care services. Since an urgent care visit was provided the correct copayment has been applied. Urgent care services fall within the urgently needed services/in-network 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 urgent care services provided on October 13, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician's services provided on August 6, 2018.You asked the Plan to pay forthe physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 nota network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would requirethe Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forphysician's services provided on August 6, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for screening prostate specific antigen (PSA) testing provided on October 7, 2019.You asked the Plan to pay for PSA test. You say that you do not believe you are responsible to know when the previous PSA test was done and do not believe this denial is fair.The Plan denied your request. The Plan says the denial of payment for this service is correct, because you had a PSA test on June 29, 2019 and therefore 12 months had not passed before this test was performed.The Plan must follow Medicare rules. Medicare rules say that screening prostate specific antigen (PSA) testing is covered once every 12 months. We looked at the file and Medicare rules. A screening PSA test was provided to you on June 29, 2019; therefore 12 months had not passed before this test was performed. Based on this information, we decided that Medicare rules for coverage of PSA test have not been met.Therefore, we decided that the Plan does not have to pay for screening prostate specific antigen (PSA) testing provided on October 7, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (80307, 82415, 84228, 82542, G0483) provided on February 18, 2019 to May 17, 2019
You asked the Plan to pay for laboratory services. You say that you were not aware of the requirement of obtaining a prior authorization. You conducted the test ordered by the referring physician in good faith and identified the service to be medically necessary. You are a licensed and approved independent laboratory. The Plan denied your request. The Plan says it is important to know which providers are part of the Plan's network. With limited exceptions, the member may be required to use network providers to get their medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis, and cases in which the Plan authorizes use of out-of-network providers. All services obtained from out-of-network providers require 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 laboratory services (80307, 82415, 84228, 82542, G0483) provided on February 18, 2019 to May 17, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1833), wrist hand orthosis (L3916) and suspension sleeves (L2397) provided to the enrollee on September 16, 2019.
You asked the Plan to pay for the orthoses and sleeves. 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 sleeves. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeves 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. The documentation in the case file does not support that the requested wrist/hand orthosis was medically reasonable and necessary for the enrollee in this case. An appropriate history and a physical examination of the wrist would reasonably be required to adequately assess whether the wrist/hand orthosis was medically reasonable and necessary. The documentation does not support that the wrist/hand orthosis was medically reasonable and necessary in this case, as there is no documentation of a credible physical examination of the wrist. 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 sleeves have not been met. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (L1833), wrist hand orthosis (L3916) and suspension sleeves (L2397) provided to the enrollee on September 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power operated vehicle, group 1 standard (K0800).You asked the Plan to pre-approvea power operated vehicle, group 1 standard. You say that the requested item is necessary.The Plan denied your request. The Plan says basedon the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 a power operated vehicle, group 1 standard. Our reviewer says that the item is not medically necessary. Our physician reviewer found there are mobility and MRADL deficits. However, the records do not indicate that an ultra-lightweight wheelchair could not safelyand adequately address ongoing needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power operated vehicle, group 1 standard have not been met.Therefore,we decided that the Plan does not have to pre-approvea power operated vehicle, group 1 standard (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for battery for use in hearing device (CPT Code V5266) purchased on August 1, 2019.
You asked the Plan to pay for the item. You say that Medicare has always covered the cost of the Cochlear implant batteries in the past and that when Cochlear stopped selling the batteries they took care of the Medicare claim and referred all sales to cochlear batteries.com. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the item have not been met. This item is not covered under Medicare or the Health Plan. Therefore, we decided that the Plan does not have to pay for battery for use in hearing device (CPT Code V5266) purchased on August 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forhigh index lenses (V2783) purchased on October 5, 2019.You asked the Plan to pay forthe high index lenses. You say that you would like to appeal the index lenses because it does not specifically says in the EOC that these lenses re excluded. If something is excluded it needs to be listed.The Plan denied your request. The Plan says this item is considered a lens option and isnot a covered benefit under the eyewear allowance.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 coveragerules apply in this case. The Plan covers these services when Routine eyewear includes the lenses and 1 pair of frames or contact lenses every 2 years. You must receive your vision services from a network provider. A prior authorization is required if you are seeking non-emergency out of network care.We looked at the file and the Plan's rules. you are responsible for paying the full cost of services that aren't covered by the plan either because they are not covered services or they were obtained out-of-network and was not authorized. Based on this information, we decided that the Plan's rules for coverage of the high index lenses have not been met.Therefore, we decided that the Plan does not have to pay forhigh index lenses (V2783) purchased on October 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent nursing facility care (99309), and behavioral health screenings (G8433, G8734, G9919, G9922) provided on July 18, 2019 by the out of network provider. You asked the Plan to pay forsubsequent nursing facility care and behavioral health screenings. You say that you go to the facilities to provide requested services. You serve all patients presented by the facilities as patients have no other treatment options due to their significant health, mobility, and behavioral health needs. Patients are often seen prior to verification of their insurances and all patients presented by the facilities are served regardless of their insurance status. This situation put them at a disadvantage of not being able to get pre-authorization but you need to meet the needs of this vulnerable population as quickly as possible.The Plan denied your request. The Plan says payment is denied because the services were not authorized. The provider did not contact the Health Plan for authorization ofthe services. The Plan requires the member to obtain covered services from Plan providers except for emergency care and out-of-area urgent care. The Health Plan did not authorize the monthly follow up services provided to 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 forsubsequent nursing facility care (99309), and behavioral health screenings (G8433, G8734, G9919, G9922) provided on July 18, 2019 by the out of network provider.