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

We decided that the Plan does not have to reduce the coinsurance forthe specialist office visit, the ophthalmic biometry services, the cataract surgeries, the operating rooms, and the anesthesia provided from January 7, 2020 to February 6, 2020.You asked the Plan to reduce the coinsurance forthe specialist office visit, the ophthalmic biometry services, the cataract surgeries,the operating rooms,and the anesthesia. You say that you would like the surgeries to be covered at the in-network benefit because you were not aware the provider was out-of-network.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 40% of the total cost for members eligible for the Medicare-covered services. You have been asked to pay a total of $2,147.20for the specialist office visit, the ophthalmic biometry services, the cataract surgeries, the operating room, and the anesthesia. The specialist office visitand the cataract surgeries fallwithin the "Physician/Practitioner services, including doctor's office visits" benefit category. The ophthalmic biometry services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The operating roomsand the anesthesia fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the providers are out-of-network. 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 reduce the coinsurance forthe specialist office visit, the ophthalmic biometry services, the cataract surgeries, the operating rooms, and the anesthesia provided from January 7, 2020 to February 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe open sided MRI services provided on September 4, 2019, September 10, 2019, and September 16, 2019.You asked the Plan to waive the coinsurance forthe open sided MRI services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the claims have been processed correctly per the enrollee's plan benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for outpatient diagnostic tests. The enrollee's contract with the Plan clearly says that enrollees will pay $0for outpatient diagnostic testsif they are eligible for Medicare cost-sharing assistance under Medicaid.The enrollee has been asked to pay 20% coinsurancefor the open sided MRI services. The open sided MRI services fallwithin the outpatient diagnostic tests benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe open sided MRI services provided on September 4, 2019, September 10, 2019, and September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (T1020) provided on December 1, 2019, to December 31, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code T1020 is assigned a status indicator of "I" under the Physician Fee Schedule, which 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (T1020) provided on December 1, 2019, to December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an automated external defibrillator (AED) garment (Lifevest) provided by an out-of-network provider on January 19, 2020.
You asked the Plan to pay for Lifevest. You say that it is often unclear to you whether a prior authorization is required, and this claim meets Medicare coverage criteria. The Plan denied your request. The Plan says the denial of payment for this item is correct, because this provider is out-of-network with the Plan and there was not a valid referral from a participating 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 require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an automated external defibrillator (AED) garment (Lifevest) provided by an out-of-network provider on January 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from January 27, 2020 through January 28, 2020.
You asked the Plan to pay for inpatient mental health care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found based upon review the records provided for the admission of this patient does not meet criteria for acute inpatient mental health treatment as the enrollee was not shown to be a danger to themselves or others, auditory or visual hallucinations. The enrollee is noted to be cooperative and compliant with treatment while not showing any acute threat to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from January 27, 2020 through January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve evaluation and possible cataract surgery to be provided
by an out of network (OON) provider.
You asked the Plan to pre-approve the OON ophthalmology services/cataract surgery. You say that the
requested OON provider is the only one you found that has the equipment necessary for a light-adjustable lens
(LAL). You feel that this should be approved. The Plan denied your request. The Plan says it was confirmed
that your current eye surgeon does have the equipment to provide placement of the LAL. Although you had
some negative side effects from the standard cataract surgery, there is no evidence that this surgeon cannot
provide the LAL you are requesting.
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 care that cannot be provided by network providers.
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
evaluation and possible cataract surgery to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown provided on March 23, 2020.
You asked the Plan to pay for the crown. You say that you were advised by the Plan that this service would be covered under your medical coverage, and not your dental coverage. The Plan denied your request. The Plan says Medicare does not cover routine dental services, and your plan does not cover crowns.
Medicare generally does not cover dental services. The Plan follows the same rule. 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. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the crown provided on March 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 8, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 29, 2020.
You asked the Plan to pay for the office visit. 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 not a network provider with the Plan. 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 an office visit provided on January 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from May 19, 2019 to May 24, 2019. You asked the Plan to waive the copayment for inpatient stay. You say that you believe your maximum out-of-pocket amount had been met at the time of service. The Plan denied your request. The Plan says the copayment amount you are being charged is correct. The Plan also says that they agree your maximum out-of-pocket amount for 2019 was exceeded by this copayment, so the Plan reduced your copayment responsibility from $1,410.60 to $560.60 which meets your 2019 maximum out-of-pocket 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 $350 copayment per day for days 1 to 5 for inpatient hospital care, up to a maximum out-of-pocket amount of $6,000 for 2019. At the time this claim was processed, $5,439.40 of the $6,000 maximum out-of-pocket amount had been met. This inpatient hospital stay lasted 5 days, resulting in a copayment obligation of $560.60 because this amount met the $6,000 maximum out-of-pocket amount for 2019. You have been asked to pay $350 copayment per day for days 1 to 5 for inpatient stay. Inpatient stay falls within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from May 19, 2019 to May 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta.You asked the Plan to pre-approve the Neulasta. You say that you would like reconsideration because the requested drug is medically necessary.The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.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 the Neulasta. Our reviewer says that the health plan requires the use of Udenyca or Fulphila before they will approve the requested drug. There is no documentation that these of been tried or why they could not be utilized. Our physician reviewer found this service is not reasonable or medically 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 the Neulasta have not been met.Therefore, we decided that the Plan does not have to pre-approve Neulasta.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a transvaginal ultrasound provided on February 13, 2020.
You asked the Plan to waive the copayment for a transvaginal ultrasound. You say that you did not receive services at an outpatient hospital facility and you should only owe a $40 copayment. 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 $40 copayment for diagnostic radiology provided in an office or imaging center and a $150 copayment for diagnostic radiology provided in an outpatient hospital facility. The record shows that you received a transvaginal ultrasound at an outpatient hospital facility on February 13, 2020. Therefore, you are responsible to pay the $150 copayment. You have been asked to pay a $150 copayment for a transvaginal ultrasound. A transvaginal ultrasound 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 a transvaginal ultrasound provided on February 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded 80307 and G0482 provided on October 29, 2019.You asked the Plan to pay forthe drug testing. 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.We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the documentation does notsupport evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing coded 80307 and G0482 provided on October 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on March 10, 2020.You asked the Plan to pay for the extraction. You say that you inquired at the dentist office twice about what you owed, and were told both times that you did not owe anything, and it would be covered by your insurance. You also say that you were not informed that this provider was not in-network.The Plan denied your request. The Plan says the treating provider has been identified as a Medicare opt out provider, and may not receive payment from the Plan or Medicare for the services rendered.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay for the extraction provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a vitrectomy provided on January 24, 2020.
You asked the Plan to waive the copayment for a vitrectomy. You say that the facility was freestanding and
you should only owe $225 not $325. 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 $325
copayment for surgery services provided in an outpatient hospital facility.
The record shows that you received a vitrectomy at an outpatient hospital facility on January 24, 2020.
Therefore, you are responsible to pay the $325 copayment.
You have been asked to pay a $325 copayment for a vitrectomy. A vitrectomy 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 a vitrectomy provided on
January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 7, 2019.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the claim was submitted untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the office visit was not filed until March 3, 2020.. This means that more than
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the
Plan does not have to pay for the office visit provided on February 7, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for podiatry services provided on February 10, 2020. You asked the Plan to waive the copayment for podiatry services. You say that you disagree with the charges because you received routine foot care. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide medical records. Without medical records we cannot determine what type of services were rendered. Therefore, we decided that the Plan has to waive the copayment for podiatry services provided on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 23, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on December 18, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says prior authorization was not 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 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 outpatient services provided on December 18,
2019 by an out of network (OON) provider.