Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lower partial denture (D5214) provided by the physician on July 16, 2019.
You asked the Plan to pay for the lower partial denture. You say that the provider was previously in network. You paid for the services in full and would like to be reimbursed. The Plan denied your request. The Plan says services performed by an out of network provider are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the lower partial denture (D5214) provided by the physician on July 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for urgent care physician's services provided.
You asked the Plan to reimburse you for the urgent care services. You say that the Plan should reimburse you the difference you paid for the urgent care visit and the actual expenses that you have paid to the provider. The Plan denied your request. The Plan says there is a $90 copay per urgent care visits outside the U.S.
Medicare says that health plans must pay for emergency and urgently needed services. The health plan contract says that urgently needed services are covered worldwide and there is a $90 copay per urgent care visit outside of the U.S. We looked at the file and Medicare rules. The file shows that you paid $85 for the urgent care physician's services, which is less than the $90 copay. Therefore, we decided that the Plan does not have to reimburse you for an urgent care services provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe "provider" testing provided on April 19, 2019 by the out of network provider.Youasked the Plan to pay forthe laboratory testing. You say that the "provider" is the only service provider of the "provider" testing.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the specialist consult and lab work were available in network. The Plan also says that the services were not urgent or emergent.Medicare rules say that plans can require enrollees to get care from network providers. The contractwith 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 networkproviders 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 "provider" testing provided on April 19, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) and periodic oral evaluation - established patient (D0120) provided by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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 provider is not in-network and your EOC clearly states, enrollees must pay 100% for out-of-network dental services. Therefore, we decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) and periodic oral evaluation - established patient (D0120) provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 5, 2019 by an out of network 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 no prior authorization was obtained for the service in question.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on June 5, 2019 by the out of network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services rendered to "the beneficiary" by "the provider" on May 13, 2019 to May 31, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that a treatment authorization code is required for home health claims.We looked at the fileand Medicare rules. The claim for the home health services was not billed with a valid treatment authorization code. 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 forthe home health services rendered to "the beneficiary" by "the provider" on May 13, 2019 to May 31, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee by the provider on June 3, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on June 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided on July 24, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the physician must clearly document, in the medical records, his or her intent that the test 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 met.Therefore, we decided that the Plan does not have to pay for drug testing services provided on July 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on March 26, 2019 by an out of network provider,.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-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 referring provider is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on March 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services provided on May 8, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says Current Procedural Terminology (CPT) 99153 remains not supported.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 code 99153 is not supported in the medical record. Specifically, payment for this code is included in the payment to the facility. This code is not separately reimbursable. 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 moderate sedation services provided on May 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on June 13, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. Thismeans that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on June 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services (99343 and 99348) provided on February 6, 2019 to February 27, 2019 by an out of network provider.You asked the Plan to pay for the home visits. You say that you have been working to obtain credentialing with the Plan and Medicare. The Plan denied your request. The Plan says they require utilization of network providers when possible and available and require 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 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 (99343 and 99348) provided on February 6, 2019 to February 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 21, 2019 by out of network (OON) provider, "the doctor" .You asked thePlan to pay forthe medical visit. You say that you feel that this should be covered because the doctor told you it would be.The Plan denied your request. The Plan says you received non-emergency care from an OON provider without authorization. This is not covered by your plan.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 medical services provided on August 21, 2019 by out of network (OON) provider, "the doctor".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran office visit provided by "the provider" on June 18, 2019.You asked the Plan to waive the copayment foran office visit. You say that this was an annual wellness visit andyou 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 sharinginformation (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for each primary care provider visit. The medical records show that you received services beyond an annual wellnessvisit on June 18, 2019. Therefore, you are responsible to pay the $20 copayment. You have been asked to pay a $20 copayment for an office visit. An office 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 foran office visit provided by "the provider" on June 18, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99215) and electrocardiogram (93000) provided on May 8, 2019.You asked the Plan to pay forthe office visit and electrocardiogram. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  We looked at the file and Medicare rules. The file shows that the services provided were neither emergent nor urgent and were not provided due to an unforeseen illness or condition. The file does not show that these services were pre-approved. Based on this information, we decided that Medicare rules for coverage of the office visit and electrocardiogram have not been met.Therefore, we decided that the Plan does not have to pay forthe office visit (99215) and electrocardiogram (93000) provided on May 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forlab services provided to the enrollee on May 30, 2019.You asked the Planto pay forthe services. You say that  The Plandenied your request. The Plansaysthe results of the testing did not directly impact treatment of the enrollee, because the ordering provider had never seen the enrollee.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 pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the available documentation does not support that the Pharmacogenetics (PGx) panel at issue in this casewas medically reasonable and necessary. It is not documented how this panel would impact the management and health of 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 services have not been met.Therefore, we decided that the Plandoes not haveto pay forlab services provided to the enrollee on May 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee from May 24, 2019 through May 29, 2019.You asked the Plan to pay forinpatient 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 this enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others being compliant with treatment. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. This patient was treated under an individualized treatment plan discussed in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided, for the admission of this patient does not meet the criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to himself or others but was without agitation or aggression without auditory or visual hallucinations.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for home delivered meals provided from August 9, 2019 to August 21, 2019.
You asked the Plan to pay for the meals. You say that this should be paid for. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. You are not eligible to bill Medicare. The plan did not pre-approve the meals. We found no exception that would require the plan to pay for these items/services. Based on this information, we decided that Medicare rules for coverage of the meals have not been met. Therefore, we decided that the Plan does not have to pay for home delivered meals provided from August 9, 2019 to August 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe facet joint injections provided on July 25, 2019.You asked the Plan to waive the cost share forthe facet joint injections. You say that you were not informed you had a deductible to meet. You say that you would have discussed otheroptions if you knew.The Plan denied your request. The Plan says the cost share applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Outpatient surgery is applied to the deductible. Your contract with the Plan also says that after you pay your $1,000 deductible, you pay a $195 copayment for outpatient surgery at an outpatient hospital.The item or service you asked the Plan to waive the cost share for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 deductible applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the facet joint injections were received on July 25, 2019. Since your $1,000 deductible was met, you have also been asked to pay a $195 copayment for the facet joint injections. 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 cost share forthe facet joint injections provided on July 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe SPECT imaging provided on August 6, 2019.You asked the Plan to reduce the copayment forthe SPECT imaging. You say that you do not think the service you had is a radiology scan. The Plandenied 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 $250 copayment per day for Medicare-covered diagnostic radiology services. You have been asked to pay a $250 copayment for the SPECT test. The SPECT test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows that a SPECT imaging is considered nuclear cardiac imaging. The medical record shows SPECT imaging was performed.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 copayment forthe SPECT imaging provided by"the doctor" on August 6, 2019.