Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (code D0210), comprehensive oral evaluation (code D0150), and four 2D oral/facial photographic images (code D0350 x4) provided on August 22, 2019.You asked the Plan to pay forthe intraoral x-rays, comprehensive oral evaluation, and 2D oral/facial photographic images. You say that you were not informed that these services would not be covered. You also say that you were under the impression that thePlan covered these services.The Plan denied your request. The Plan says you must use network providers to get covered services. The Plan also says that the provider who rendered these services is not a network provider.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.   The record shows that the provider will not be charging you for these services due to an office error in having a non-contracted provider render the services to you. Though the denial is upheld, you might not have to pay for the services.Therefore, we decided that the Plan does not have to pay forthe complete series of intraoral x-rays (code D0210), comprehensive oral evaluation (code D0150), and four 2D oral/facial photographic images(code D0350 x4) provided on August 22, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on September 4, 2019 by out of network provider.You asked the Plan to pay forpsychotherapy. You say that you have been a patient of the physician for 34 years. You say that since this psychiatrist works for you that you want to continue seeing him.The Plan denied your request. The Plan says the provider is not contracted and prior authorization was not obtained from the Plan. The Plan further says that the services provided were not urgent or emergent and could have been provided by a contracted provider.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 requirethe Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forpsychotherapy provided on September 4, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on August 15, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 has network providers available who can provide 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 forthe medical services provided by an out-of-network provider on August 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Perforomist nebulizer solution for the enrollee.You asked the Plan to pre-approvea tier exception. You say that the enrollee needs this for chronic obstructive pulmonary disease.The Plan denied your request. The Plan says that Part B drugs are not eligible for tier cost exception.The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met.Therefore, we decided that the Plan does not have to pre-approvea tier exception for Perforomist nebulizer solution for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT angiography provided on March 19, 2019.You asked the Plan to waive the copayment fora CT angiography. You say that you were never told that you would owe a copayment.The Plan denied your request. ThePlan 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 $0 copayment for mammography and ultrasounds and a $270 copayment for all other diagnostic radiology services. You have been asked to pay the allowed amount of $261.45, which is less than the $270copayment for a CT angiography. A CT angiography 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 fora CT angiography provided on March 19, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99213) provided on March 18, 2019 by out of network provider.You asked the Plan to pay for an office visit. You say that you want the Plan to reconsider denial of payment for these services. You say that effective treatment provided was medically necessary to manage the consumer's illness and prevent episodes of decompensation. You further say that exacerbation of symptoms would result in requiring a higher level of care as well as monetary resources.The Plan denied your request. The Plan says they require the utilization of in-network providers unless the plan pre-approves out of network services in non-emergent situations. The Plan says that the provider did not make attempts to verify the member's correct insurance, eligibility, or authorization requirements prior to rendering non-emergent services. The Plan further says that there is no evidence of Plan directed care. The provider did not provide good cause for why prior authorization was not requested. The plan stands by the denial of out of network services provided without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foran office visit (99213) provided on March 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 medical services provided by an out-of-network provider on August 14, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 has network providers available who canprovide 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 forthe medical services provided by an out-of-network provider on August 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on August 12, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 has network providers available who can provide 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 forthe medical services provided to by an out-of-network provider on August 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on July 15, 2019.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 has network providers available who can provide the servicesat 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 forthe medical services provided by an out-of-network provider on July 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on September 25, 2019.You asked the Plan to waive the copayment for arthrocentesis. You say that you disagree with being charged two $50 copayments.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 $50 copayment for each specialist visit. You have been asked to pay a $50 copayment for arthrocentesis. Arthrocentesis falls within the outpatient hospital 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 forarthrocentesis provided on September 25, 2019
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided from March 16, 2019 to March 17, 2019.You asked the Plan to pay forthe hospital services. You say that the enrollee was discharged on March 11, 2019.The Plan denied your request. The Plan says that under Medicare guidelines, Original or Traditional Medicare is still responsible for payment until the start of the next month after the hospice revocation.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on March 11, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forhospital services provided from March 16, 2019 to March 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring services coded 95941 provided on August 23, 2018.You asked the Plan to pay forthe continuous intraoperative neurophysiology monitoring 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 payable.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 95941 is Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure).We find that CPT code 95941 is not supported in the medical record. Specifically, code 95941 has a statuscode of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of the continuous intraoperative neurophysiology monitoring services have not been met.Therefore, we decided that the Plan does not have to pay forthe continuous intraoperative neurophysiology monitoring services coded 95941 provided on August 23, 2018
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.You asked the Plan to pre-approve Synvisc-One. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not medically necessary.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Synvisc-One. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the documentation does not support that the enrollee has tried and failed a trial of Monovisc and Orthovisc (Hyaluronic acid). The documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. It is noted that Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. The enrollee has not received Synvisc-One since June 5, 2018, and therefore would not be considered to be actively receiving this medication.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met.Therefore, we decided that the Plan does not haveto pre-approveSynvisc-One
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve continued home health services beyond the three approved visits.
You asked the Plan to pre-approve home health services. You say that the enrollee needs to be monitored after this hospital stay to ensure stability and to prevent readmission. The Plan denied your request. The Plan says that the enrollee has received many home health visits over the past year and should not require any more.
The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing coverage of home care services. There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services at issue in this appeal. Therefore, we decided that the Plan has to pre-approve continued home health services beyond the three approved visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta injections.
You asked the Plan to pre-approve the Neulasta injections. You say that you need this drug to increase your white blood cells to help with infections. You need your white blood cells elevated in order to continue receiving the clinical trial drug. The Plan denied your request. The Plan says this is being requested to allow you to continue with a clinical trial. The clinical trial should provide this treatment and bill the services to the Original Medicare contractor as a routine cost.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the Neulasta injections as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Neulasta injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel 50mg/mL mini cartridges.
You asked the Plan to pre-approve the Enbrel cartridges. You say that this is a medically necessary drug. The Plan denied your request. The Plan says this self-injected drug cannot be covered by Medicare 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 Enbrel 50mg/mL mini cartridges.
Benefits for the Enbrel cartridges 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on June 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services
rendered by non-participating providers in non-participating facilities require prior authorization as outlined in
the enrollee's EOC.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide 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 medical services provided to the enrollee by an out-of-network provider on
June 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin debridement provided on May 31,
2019.
You asked the Plan to waive the copayment for the skin debridement. You say that you were not informed that
the service would not be covered by your insurance. You say bandaging the wound have been included in the
original charge. The Plan denied your request. The Plan says you have been charged the correct cost sharing
amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395
copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital,
including but not limited to hospital or other facility charges and physician or surgical charges. For this date of
service, you have been asked to pay the allowed amount of the claim because this amount is less than the $395
copayment for the skin debridement.
You have been asked to pay a $282.72 copayment for the skin debridement. The skin debridement 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 the skin debridement
provided on May 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation.You asked the Plan to pre-approve routine transportation. The Plan denied your request. The Plan says transportation is not covered by your benefit plan.The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of transportation have not been met.Therefore, we decided that the Plan does not have to pre-approve routine transportation
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the MD certification services provided on October 1, 2019
by out of network doctor.
You asked the Plan to pay for the MD certification. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the MD certification services provided on October
1, 2019 by out of network doctor.