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

We decided that the Plan does not have to pay for the oral surgery services provided on April 11, 2019 by an out of network provider.
You asked the Plan to pay for these services. You say that you tripped and fell and were advised you had a broken jaw. The Plan denied your request. The Plan says the services were rendered by a non-contracted 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, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The referring provider 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 oral surgery services provided on April 11, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitoring
system.
You asked the Plan to pre-approve a continuous glucose monitoring system. You say that you need a
continuous glucose monitor. The Plan denied your request. The Plan says there is not documentation of insulin
injections, adjustment of dosage, or testing.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they
are medically reasonable and necessary and replace a blood glucose monitor.
We looked at the file and Medicare rules. There is no documentation supporting the criteria. Based on this
information, we decided that Medicare rules for coverage of a continuous glucose monitoring system have not
been met. Therefore, we decided that the Plan does not have to pre-approve a continuous
glucose monitoring system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Ostomy supplies (A4362, A4385, A4394, A4414, A4419, A4456 and A5120) provided on March 28, 2019 through June 26, 2019.
You asked the Plan to pay for the Ostomy supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation did not include a valid physician order.
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 shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for Ostomy supplies (A4362, A4385, A4394, A4414, A4419, A4456 and A5120) provided on March 28, 2019 through June 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary for the continuation of acute care services and the records provided demonstrate an LTACH admission to be medically appropriate. The Plan denied your request. The Plan says the enrollee is receiving medically necessary acute and/or critical care in the current hospital. The plan says that there are no issues for which an LTACH may offer a therapeutic advantage.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found ongoing care needs include oxygen supplementation, neurological monitoring, surveillance laboratory studies, telemetry monitoring, tube feeding, wound care, and therapy services. Our physician reviewer found that the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 29, 2019 by out of network provider.  You asked the Plan to pay for these services. You say that you felt that no lab in New York state could do the testing you needed. 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, 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 medical services provided on August 29, 2019 by out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 24, 2019 by out of network provide.You asked the Plan to pay for subsequent nursing facility care. You say that the physician cannot deny any medical services that are essential for patient health treatment. You also say that you depend upon the hospital staff to verify eligibility and to obtain the proper authorization needed.The Plan denied your request. The Plan says the physician, is a non-network provider who does not work with the member's health plan, and the member was referredby a physician, who also does not work with the member's plan. The member's primary care physician did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 Plandoes not have to pay forsubsequent nursing facility care provided on July 24, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that a shower chair is not a luxury but a medical
necessity. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe removal of external fixation system services coded 20694 provided on July 8, 2019.You asked the Plan to pay forthe removal of external fixation system services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 20694 is removal, under anesthesia, of external fixation system.We find that CPT code 20694 is not supported in the medical record. Specifically, the documentation did not indicate that removal, under anesthesia, of external fixation system was performed. Based on this information, we decided that Medicare rules for coverage of the removal of external fixation system services have not been met.Therefore, we decided that the Plan does not have to pay forthe removal of external fixationsystem services coded 20694 provided on July 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fora tangential biopsy of a single skin lesion (11102) provided on March 20, 2019 by out of network provider.You asked the Plan to pay fora tangential biopsy of a single skin lesion. You say that you want the medical records reviewed for medical necessity.The Plan denied your request. The Plan says the physician is a non-network provider who does not work with the member's health plan, and the member self-directed for care. The member's primary care provider did not refer for services. The health plan requires utilizationof network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 inthis 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 fora tangential biopsy of a single skin lesion (11102) provided on March 20, 2019 by out of network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve drugs or medicaments dispensed in the office for home use, first 15 minutes of deep sedation/general anesthesia, two additional 15 minute increments of deep sedation/general anesthesia, and therapeutic parenteral drug administration.You asked the Plan to pre-approvethe drugs or medicaments, deep sedation/general anesthesia services, and therapeutic parenteral drug administration. You say that you are in pain and need to have teeth surgically extracted.The Plan denied your request. The Plan says these services are not covered under your benefit package.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 pre-approvedrugs or medicaments dispensed in the office for home use, first 15 minutes ofdeep sedation/general anesthesia, two additional 15 minute increments of deep sedation/general anesthesia, and therapeutic parenteral drug administration.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services rendered to you on May 28, 2019 to August 6, 2019.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 provider has opted out of Medicare.The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare. We looked at case file and the Medicare rules. We confirmed that the physician has opted out of Medicare. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the physician services rendered to you on May 28, 2019 to August 6, 2019.
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 January 23, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.
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 January 23, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99202), electrical stimulation (G0283), mechanical traction (97012), hot/cold packs (97010) and therapeutic exercises (97110) provided on August 20, 2019 through August 22, 2019.
You asked the Plan to pay for the chiropractic services. You say that you were informed by the Plan that these services would be covered. The Plan denied your request. The Plan says only manual manipulation of the spine is covered, other services performed by a chiropractor are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an office visit (99202), electrical stimulation (G0283), mechanical traction (97012), hot/cold packs (97010) and therapeutic exercises (97110) provided on August 20, 2019 through August 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystoscopy provided on August 5, 2019.
You asked the Plan to waive the copayment for the cystoscopy. You say that you did not have any type of surgery. You say that you shouldn't have to pay a copayment for something you didn't have. The Plan denied your request. The Plan says the 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 $400 copayment for all other outpatient services including observation and outpatient surgical services not provided in an ambulatory surgical center. You have been asked to pay a $400 copayment for the cystoscopy. The cystoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The cystoscopy is considered a surgical procedure. 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 cystoscopy provided on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 25, 2019 to July 3, 2019 by an out of network provider.
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 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, 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 medical services provided on June 25, 2019 to July 3, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, debridement, and the chemical cauterization services provided on April 8, 2019 by an out of network provider.  You asked the Plan to pay for the subsequent nursing facility care, debridement, and the chemical cauterization services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided 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 subsequent nursing facility care, debridement, and the chemical cauterization services provided on April 8, 2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture (code D5225) provided on July 23, 2019.
You asked the Plan to pay for the maxillary partial denture. You say that you were told that a new partial would be fully covered by your plan. You also say that after the partial came in you were told that you have to pay the entire amount. The Plan denied your request. The Plan says this service is not covered by the 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the maxillary partial denture (code D5225) provided on July 23, 2019.
Appeal type: Lab
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 August 22, 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 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 August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wig any type (A9282) to be provided by the provider.  You asked the Plan to pre-approve the wig. You say that you need the wig because it will improve the
emotional impact that losing your hair has taken on your mental health. The Plan denied your request. The Plan
says this item 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 pre-approve wig any type (A9282) to be provided by the provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 18, 2019 by the out of network provider.  You asked the Plan to pay for outpatient lab work. You say that the doctor does not care that the lab doesn't participate with the plan.  You say that he treats his patients and doesn't care about the business aspect of insurance. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The referring provider is also out-of-network. 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 medical services provided on June 18, 2019 by the out of network provider.