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

We decided that the Plan does not have to pay for the lab services provided on January 6, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the enrollee's
plan requires utilization of network providers, and authorization for certain services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the lab services provided on January 6, 2020 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 prophylaxis and first intraoral periapical x-ray provided on February 10, 2020.
You asked the Plan to pay for the prophylaxis and first intraoral periapical x-ray. You say that you were told by the Plan that this provider was in-network with the Plan, but you can go to any dentist. You also say that you were told you have $2,000 worth dental coverage. 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 prophylaxis and first intraoral periapical x-ray provided on February 10, 2020.
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 January 10, 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 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 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on October 21, 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. The Plan says that the member's primary care physician did not refer 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 outpatient services provided on October 21, 2019 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 outpatient mental health services (90837) provided February 20 to April 14, 2020.You asked the Plan to pay for the outpatient mental health services. You say that you were told the provider was in-network and the services should be covered.The Plan denied your request. The Plan says the provider that performed the services at issue is not eligible to receive Medicare payment.The Plan must follow Medicare rules. Medicare rules say that Licensed Professional Counselors (LPC's) are not eligible for enrollment in the Medicare program. We looked at the file and Medicare rules.The provider at issue is a Licensed Professional Counselor and is not eligible for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have not been met.Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90837) provided February 20 to April 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on June 8, 2019.You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation shows that the sample for testing was taken in an outpatient rehabilitation facility, therefore the Place of Service code 11 -indicating an office setting -is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to pay for drug testing provided on June 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on August 21, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99190 is assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour. We find that CPT code 99190 is not supported in the medical record. Specifically, the enrollee was inpatient for these services billed. Payment for these services while the enrollee was inpatient is included in the Part A DRG payment to the facility. Payment for this service is the responsibility of the facility and cannot be separately paid. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of pump with oxygenator or heat exchanger services have not been met. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on August 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded 80307 and G0483 provided on July 12, 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 G0483 are not supported in the medical record. Specifically, the documentation did not containsufficient detail to support the billed charges. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 11; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a facility rehabilitation setting place of service 55. 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 G0483 provided on July 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections provided on April 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for injections. You say that you organized to have these injections out-of-state. 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 injections provided on April 9, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a neurology visit.
You asked the Plan to pre-approve the neurology visit. You say that you would like reconsideration because
your symptoms have been worsening and the commute to the recommended provider is a concern. The Plan
denied your request. The Plan says that these services are available in-network.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is
considered accessible to an enrollee if contract providers are available within reasonable distance and travel
time from the enrollee's home. The Plan says that enrollees must use contract providers.
The provider is a non-contract provider. The Plan's recommended provider is outside of the Medicare
accessibility guidelines. There is another Plan provider mentioned, but the record indicates that they are not
taking new patients at this time. The Plan is not able to provide an accessible in-network option in this case.
Under Medicare rules, this means that contract providers are not accessible to you. Therefore, we decided that
the Plan has to pre-approve a neurology visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the office visit (99215) and the mechanical
traction therapy (97012) provided on November 26, 2019.
You asked the Plan to issue reimbursement for these services. You say that you are requesting a
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are
not a covered benefit under your contractual policy.
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 services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to issue reimbursement for the office visit (99215) and the mechanical traction
therapy (97012) provided on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation, bitewings, and prophylaxis provided on February 25, 2020 by an OON provider.You asked the Plan to pay forthe periodic oral evaluation, bitewings, and prophylaxis. You say that prior to your appointment you reviewed your dental benefits, and said it does not reference anywhere that the dentist must be contracted by the Plan in order to receive payment. You also say that you asked the provider if they accepted your insurance plan and were told that they did.The Plan denied your request. The Plan says these services were rendered by a provider who is not under contract with 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 covered when they are received OON.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation, bitewings, and prophylaxis provided on February 25, 2020 by an OON provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the evaluation of speech sound production
provided on July 11, 2019.
You asked the Plan to waive the copayment for the evaluation of speech sound production. You say that you
should only owe a $45 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 $50
copayment.
You received the evaluation of speech sound production on July 11, 2019. The evaluation of speech sound
production is considered a diagnostic procedure. Therefore, you are responsible to pay the $50 copayment.
You have been asked to pay a $50 copayment for the evaluation of speech sound production. The evaluation of
speech sound production 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 the evaluation of speech sound
production provided on July 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309)
rendered by the out of network (OON) provider on March 24, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not
have to pay for the subsequent nursing facility care, per day (99309) rendered by the out of network (OON)
provider on March 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic services provided on March 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for diagnostic 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. The plan says that the referring provider is also 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 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 diagnostic services provided on March 13, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PILD.
You asked the Plan to pre-approve PILD. You say that you would like reconsideration because the member's condition has greatly affected the member's quality of daily living. The Plan denied your request. The Plan says there is not sufficient high-quality literature to support the durable health benefit of this treatment for a diagnosis of lumbar stenosis.
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 PILD. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the PILD procedure is experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PILD have not been met. Therefore, we decided that the Plan does not have to pre-approve PILD.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin lesion destruction procedure provided on February 25, 2020.
You asked the Plan to waive the copayment for the skin lesion destruction procedure. You say that the procedure took place at your doctor's office. You say you were told this procedure was covered. 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 $225 copayment for each Medicare-covered in-network outpatient hospital facility visits. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $225 copayment for the skin lesion destruction procedure.
You have been asked to pay a $124 copayment for the skin lesion destruction procedure. The skin lesion destruction procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the skin lesion destruction procedure provided on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0675, E0673).You asked the Plan to pay fora pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. A PCD defined by E0675 is a noncovered item.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0675, E0673).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the enhanced steering perform unit (K0108).
You asked the Plan to pay for the enhanced steering perform unit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this supply cannot be requested separately.
The Plan follows Medicare rules. Medicare rules say that code K0108 must not be used for any component or feature of an expandable controller at the time of initial issue. 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 enhanced steering perform unit. Our reviewer says that the guidelines state that this code K0108 should only be used if components of the harness are replaced which is not the case per the submitted documentation. Our physician reviewer found the documentation does not indicate that the patient requires the requested K0108 to safely operate the approved Group 3 power wheelchair. 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 enhanced steering perform unit have not been met. Therefore, we decided that the Plan does not have to pay for the enhanced steering perform unit (K0108).