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

We decided that the Plan does not have to pay for the laparoscopy provided on December 8, 2020.
You asked the Plan to pay for the laparoscopy provided by a surgical assistant. You say that this code is
payable to the assistant surgeon. The Plan denied your request. The Plan says the provider billed with a
specialty that is not allowed per CMS.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for the laparoscopy provided on
December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 8,
2021.
You asked the Plan to waive the copayment for the office visit. You say that you were having pain and the
doctor never suggested a more extensive test. You say that you drove 50 minutes for nothing and do not want
to pay for the specialist. 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 $45 for
each Medicare-covered visit with an in-network specialist.
You have been asked to pay a $45 copayment for the office visit. The office visit falls within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The records show that
services were provided during the visit. 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 office
visit provided on January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on January 9, 2021.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.
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 laboratory services provided by an out-of-network provider on January 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ground mileage (A0425) provided on March 24, 2020.
You asked the Plan to pay for ground mileage. You say that you want the Plan to pay. The Plan denied your request. The Plan says the service is not covered because the billed units exceed the MUE value for this procedure code.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code A0425 is 250. You billed 345 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of ground mileage have not been met.
Therefore, we decided that the Plan does not have to pay for ground mileage (A0425) provided on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 7, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 had network providers available who could have provided 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 services provided by an out-of-network provider on December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on January 14, 2021.

You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says the eye refraction is not a covered benefit since it was a medical vision check.

The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. 

We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on January 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a molecular pathology procedure, level 5 (81404, 81479) provided on November 9, 2020.

You asked the Plan to pay for a molecular pathology procedure. You say that the services were provided, and payment should be rendered. The Plan denied your request. The Plan says the services are non-covered.

The Plan must follow Medicare rules. Medicare rules say that there is no Medicare benefit for screening cardiovascular (CV) risk assessment testing for asymptomatic (without signs or symptoms of disease) patients.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a molecular pathology procedure have been met. Therefore, we decided that the Plan does not have to pay for a molecular pathology procedure, level 5 (81404, 81479) provided on November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on September 7, 2020, by
an OON 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 had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the nursing facility care provided on September 7,
2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 1, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 had network providers available who could have provided 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 services provided by an out-of-network provider on December 1, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on October 20, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because these services were rendered in good faith without time to obtain authorization. The Plan denied your request. The Plan says psychotherapy services require prior authorization and the Plan requires the utilization of network providers unless out-of-network services are pre-approved in non-emergent situations.

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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90837) provided on October 20, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic treatment provided on January 15, 2021 by an out of network (OON) provider.You asked the Plan to pay forthe chiropractic treatment. You say that the service is medically necessary, and your insurance has covered this service in thepast. The Plan denied your request. The Plan says the provider is out-of-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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay forthe chiropractic treatment provided on January 15, 2021 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on September 17, 2020.

You asked the Plan to pay for the psychotherapy. You say that the service was provided with no adequate time to obtain authorization. You say that the records reflect the medical necessity of the service and the claim should be processed for payment. The Plan denied your request. The Plan says authorization for out of network services 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 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 psychotherapy provided by an out-of-network provider on September 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a PET scan provided by a participating provider on December 16, 2020.
You asked the Plan to waive the coinsurance for a PET scan. You say that you would have waited if you knew that it was going to cost this much. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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 20% coinsurance for outpatient diagnostic tests/PET scans/in-network. You have been asked to pay a 20% coinsurance of the allowed amount for a PET scan. The total allowed amount is $4,718.30. The total amount you are being asked to pay is $943.66 ($4,718.30 x 20% = $943.66).
The correct coinsurance has been applied to the services that were provided. A PET scan falls within the outpatient diagnostic tests/PET scans/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a PET scan provided by a participating provider on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus and diphtheria vaccine provided on August 25, 2020.
You asked the Plan to pay for the Tetanus and diphtheria vaccine. You say that the Plan should pay this claim. The Plan denied your request. The Plan says this immunization is not a Medicare covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus and diphtheria vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Tetanus and diphtheria vaccine. Therefore, we decided that the Plan does not have to pay for the Tetanus and diphtheria vaccine provided on August 25, 2020.
Benefits for the Tetanus and diphtheria vaccine 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance you received on January 13, 2021.You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says you have been asked to pay the correct amount.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 services may require payment when provided by an out-of-network provider. While the Plan does cover periodontal maintenance services, when the services are provided by an out-of-network provider, you are responsible to pay the difference between the dentist's fees and the Plan's dental fee schedule. In this case, the difference is $73, which is what you are required to pay.Therefore, we decided that the Plan does not have to pay for the periodontal maintenance you received on January 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy visit provided on September 2, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy visit. You say that the service was medically necessary. 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 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 psychotherapy visit provided on September 2, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a visual field test provided on February 22, 2021.

You asked the Plan to pay for the visual field test. 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 a visual field test provided on February 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically
necessary. The Plan denied your request. The Plan says the requested Vertiflex device is 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 a Vertiflex device. Our reviewer says
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is
with persistent back pain from spinal stenosis. The Vertiflex device remains experimental. More research is
needed to show safety and efficacy of the device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does
not have to pre-approve a Vertiflex device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency ambulance transportation (A0425, A0428) services provided on September 24, 2020.
You asked the Plan to pay for the non-emergency ambulance transportation (A0425, A0428) services. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office is not a Medicare covered benefit.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the non-emergency ambulance transportation (A0425, A0428) services. Our reviewer says that the ambulance services are not necessary. Our physician reviewer found that the medical records do not support the use of ambulance services to this enrollee's outpatient appointment. The documentation does not support that other means of transportation such as a stretcher van was contraindicated for this enrollee. 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 non-emergency ambulance transportation (A0425, A0428) services have not been met. Therefore, we decided that the Plan does not have to pay for non-emergency ambulance transportation (A0425, A0428) services provided on September 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0480, 80307) provided on January 21, 2021 by an out of network (OON) provider.
You asked the Plan to pay for OON drug testing. You say that these services were performed in good faith. 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for drug testing (G0480, 80307) provided on January 21, 2021 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on
September 23, 2020.
You asked the Plan to pay for the psychotherapy. You say that the service was provided with no adequate time
to obtain authorization. You say that the records reflect the medical necessity of the service and the claim
should be processed for payment. The Plan denied your request. The Plan says authorization for out of network
services 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 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 psychotherapy provided by an out-of-network
provider on September 23, 2020.