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

We decided that the Plan does not have to pay forthe eye exam, visual field exam, and the computerized ophthalmic diagnostic imaging provided on July 29, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe vision services. You say that the enrollee's primary care physician filed for an authorization. You also say that you were advised by the Plan that authorization was not required.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the services were not urgent or emergent in nature. The Plan also says the services could be provided 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 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 forthe eye exam, visual field exam, and the computerized ophthalmic diagnostic imaging provided on July 29, 2019 by an out of network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion with an inpatient admission.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had a previous L4-5 posterior lumbar interbody fusion in 2011. There is no evidence of SI joint fracture, instability, or tumor. The requested SI joint fusion is therefore not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve sacroiliac (SI) joint fusion with an inpatient admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on September 17, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that you did not see a provider and disagree with the 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 $50 copayment for each specialist visit. The medical records show that you had a specialist visit on September 17, 2019. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls 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 copayment fora specialist visit provided on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care providedon August 5, 2019.You asked the Plan to pay for the subsequent nursing facility care. 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 planscan 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 servicesat 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 subsequent nursing facility care provided on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99214) provided on August 8, 2019.You asked the Plan to pay foran office visit. You say that the physician met with the enrollee to discuss her condition and treatment in addition to the biopsy that took place the same day.The Plan denied your request. The Plan says the submitted records do not support an office visit took place.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 99214 is office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.We find that CPT code 99214 is not supported in the medical record. Specifically, the medical records do not show that a detailed history, a detailed examination, or moderately complex decision making took place on this date of service. There is no documentation of counseling or coordination consistent with the patient's needs. Without this documentation, the billed service cannot be verified.Based on this information, we decided that Medicare rules for coverage of an office visit have not been met.Therefore, we decided that the Plan does not have to pay foran office visit (99214) provided on August 8, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe endoscopy provided on August 7, 2019.You asked the Plan to waive the copayment forthe endoscopy. You say that the surgery could not be done. You say that the charge is not right.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 $150 copayment for each visit for surgical procedures, including but not limited to cardiac catheterizations, angiogram, endoscopy, epidural injections, and non-screening colonoscopies at an outpatient hospital facility.You have been asked to pay a $150 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical records show that the procedure was cancelled after it was initiated. Thismeans 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 forthe endoscopy provided on August 7, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on October 14, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that you cannot afford to pay this.The Plan denied your request. The Plan says that cost-sharing 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 $250 copayment for each Medicare-covered trip provided by an Out-of-Network provider. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered trip provided by an Out-of-Network provider 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 forthe ambulance transport provided on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on October 23, 2019.You asked the Plan to waive the copayment for the specialist office visit. You say that the provider you saw was not a professional doctor. You say you think not think you had to pay for a check-up or a follow-up appointment. 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 $50 copayment for each Medicare-covered specialist office visit. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the provider's specialty is gastroenterology. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a check-up or as a follow-up appointment.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 specialist office visit provided on October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital clinic visit provided on May 6,2019 by an out of network (OON) provider.You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee.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 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 outpatient hospital clinic visit provided on May 6, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 5, 2019 by an out of network (OON) provider.You asked the Plan to pay for the ultrasound (76700). You say that you would likereconsideration based on the records submitted. The Plan denied your request. The Plan says the member sought non-emergent/urgent services on their own and did not allow the PCP to request approval.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 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 5, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care from June 17, 2019 through July 24, 2019.
You asked the Plan to waive the copayment for SNF care. You say that you should not be responsible for the
SNF charges due to being under the impression there would be no charge. The Plan denied your request. The
Plan says the claim was processed accordingly with your 2019 EOC 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).
Review of the file show that you received SNF care from June 17, 2019 through July 24, 2019 provided by an
in-network provider. You pay a $0 copay per day for days 1-20 and you are asked to pay a $172 copay per day
for days 21-100 for in-network Medicare-covered SNF stays. 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 SNF care from June 17, 2019 through July 24, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on August 15, 2019 and September 3, 2019.
You asked the Plan to hold you harmless for the limited oral evaluation and intraoral periapical x-ray. The Plan denied your request. The Plan says that problem focused limited oral evaluation (D0140) is not a covered service. The Plan also says that the yearly benefit was exhausted for the first intraoral periapical x-ray.
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. The Plan covers the limited oral evaluation and intraoral periapical x-ray when the services are medically necessary and reasonable. We looked at the file and Medicare rules. The rules say that the Plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your Plan.
The Plan contract says that one dental x-ray is covered per year and one oral exam is covered every 6 months. However, the contract further lists non-routine services and diagnostic services as being covered comprehensive benefits. Based on this information, we decided that the Plan's rules for coverage of the limited oral evaluation and intraoral periapical x-ray have been met. Therefore, we decided that the Plan has to hold you harmless for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on August 15, 2019 and September 3, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you were out of state and you noticed a suspicious mole on your face. You say that you should only have to pay your copayment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services did not meet the emergent/urgent services criteria.
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 office visit provided on October 15, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing care provided on August 2, 2019 to August 12, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing care. You say that these services were medically necessary and should be approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained 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 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 skilled nursing care provided on August 2, 2019 to August 12, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the lightweight wheelchair rental provided on October 17, 2019.
You asked the Plan to pay for the lightweight wheelchair rental. You say that the Plan should pay this claim
and the remaining months that will be billed. The Plan denied your request. The Plan says that an enrollee does
not own a durable medical equipment item even after paying the 13 consecutive months.
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 has not provided evidence that 13 rental payments were made.
Therefore, we decided that the Plan has to pay for the lightweight wheelchair rental provided on October 17, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the clinic visit (G0463) and electrocardiogram (93005)
provided on September 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a clinic visit and electrocardiogram. You say that you tried to get authorization
prior to this visit. The Plan denied your request. The Plan says these 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 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 clinic visit (G0463) and electrocardiogram
(93005) provided on September 11, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on April 25, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been me.t.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on April 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on October 31, 2019.
You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the charges because you were told to go to the emergency room. 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 per visit for urgently needed services provided in a medical facility or urgent care center. You have been asked to pay a $65 copayment for urgently needed services. Urgently needed services fall within the urgently needed services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for urgently needed services provided on October 31, 2019.