Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health services (90791, 90834) provided on
November 16, 2020 to December 3, 2020 by an out of network (OON) provider.

You asked the Plan to pay for mental health services. You say that you were not aware that you were not innetwork
with the enrollee's specific plan. 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 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 mental health services (90791, 90834) provided on November 16, 2020 to December 3, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 3, 2020 by an out of network (OON) provider.

You asked the Plan to pay for these services. You say that you were previously told this was a participating provider. 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 office visit provided on March 3, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee brace to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve knee brace. You say that the needed brace is not available in-network. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this provider is out-of-network with the Plan and this knee brace can be provided by an in-network supplier.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a knee brace to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the simple extractions (D7140 x 7), the surgical extractions (D7210 x 2), the immediate upper denture (D5130), and the alveoloplasty in conjunction with an extraction (D7310) provided on July 7, 2020.

You asked the Plan to pay for the dental services. You say that you were given the wrong information for receiving dental services. You say that you were told you had to see this provider. You say that you were told that the plan would only pay $700 at the time. You also say that you could not find an in network dentist. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services performed out of network 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, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the simple extractions (D7140 x 7), the surgical extractions (D7210 x 2), the immediate upper denture (D5130), and the alveoloplasty in conjunction with an extraction (D7310) provided on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric office visit provided on January 21, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the psychiatric office visit. You say that you are in-network and a referral is not required for this visit type and code. 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 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 psychiatric office visit provided on January 21, 2021 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for office visits (99214), Gel-one (J7326) and triamcinolone acetonide (J3301) provided May 13, 2020, to February 24, 2021.
You asked the Plan to waive the cost share for office visit, Gel-one, and triamcinolone acetonide. You say that you were not aware you would be receiving these charges based on your personal history receiving them before 2020. The Plan denied your request. The Plan says these claims processed correctly, and no reimbursement is due.
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 $35 copayment for physician specialist services and a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a $35 copayment for office visits and a 20% coinsurance for Gel-one and triamcinolone acetonide. These services fall within the physician specialist services and Medicare Part B prescription drugs benefit category. The Plan contract is clear that this is what you will be paying for these services. 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 for office visits (99214), Gel-one (J7326) and triamcinolone acetonide (J3301) provided May 13, 2020, to February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and pneumatic appliance (E0667).

You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you are the manufacturer and only supplier of the Flexitouch pneumatic compression device. This device prescribed to the enrollee cannot be obtained through an in-network provider. The Plan denied your request. The Plan says per the records provided, the enrollee has lymphedema of the extremities alone. The enrollee does not meet the criteria.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.

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, the records show that the enrollee has lymphedema of the extremities alone. A PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities alone even if the criteria in this section are met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and pneumatic appliance (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care services rendered on August 19, 2020.

You asked the Plan to waive the copayment for these services. You say that you were told you wouldn't be charged. The Plan denied your request. The Plan says the copayment was 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 $40 copayment for Medicare-covered emergency room visits.

Review of the file shows that you received urgent care services on August 19, 2020. You have been asked to pay a $40 copayment for these services. These services fall within the Medicare-covered urgent care 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 for the urgent care services rendered on August 19, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78815) provided October 15, 2020.
You asked the Plan to pay for the diagnostic services. You say that CPT 78815 denied as not medically necessary. Please review the attached medical records to support the services and reprocess your claim for payment. The Plan denied your request. The Plan says that the service is not medically necessary, and the enrollee does not meet the Medicare criteria.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 diagnostic services. Our reviewer says that the requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee has a lung nodule that is strongly suspicious for bronchogenic carcinoma and will be undergoing video assisted thoracoscopic surgery. The PET scan is requested for initial treatment strategy purposes. The elements of the coverage rule are satisfied, and the requested service is recommended. 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 diagnostic services have been met. Therefore, we decided that the Plan has to pay for the positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78815) provided October 15, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to waive the deductible for the inpatient stay provided from September 22, 2020, through September 23, 2020.
You asked the Plan to waive the deductible for the inpatient stay. You submitted your bill for review. The Plan denied your request. The Plan says that the deductible 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 does not say in clear and accurate terms how much you should expect to pay for inpatient hospital care in the 2020 Plan year. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $1,408 deductible for inpatient hospital care in 2020. The Plan contract only lists the 2019 benefit, and the Plan did not submit the Annual Notice of Changes that lists the 2020 inpatient hospital care benefit. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the deductible for the inpatient stay provided from September 22, 2020, through September 23, 2020.
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: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to hold you harmless for the prophylaxis. We decided that the Plan does not have to pay for the comprehensive oral evaluation.
You asked the Plan to pay for the comprehensive oral evaluation and prophylaxis. You say that you feel that you should not be held responsible for these services. The Plan says that your benefits for the comprehensive oral evaluation have been satisfied and the frequency limitation has been exceeded. The Plan also says that your provider has been informed that the initial oral examination was billed incorrectly.
We decided that the Plan has to hold you harmless for the prophylaxis.
Medicare rules say that a contract provider is an agent of the Plan. Services and referrals given by a contract provider are considered approved by the Plan unless notice is provided that the services will not be covered. The Plan follows these rules. The EOC states that prophylaxis (cleaning) is a covered benefit. The prophylaxis (cleaning) was incorrectly billed with code D0110 by the in-network provider. The Plan contacted the provider multiple times to have this code corrected, but no correction was received. You reasonably believed the prophylaxis would be covered because your EOC states that it is a covered service. Therefore, we decided that the Plan has to hold you harmless for the prophylaxis.
We also decided that the Plan does not have to pay for the comprehensive oral evaluation.
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, comprehensive oral evaluation is limited to one procedure every three years. The record shows that you received a comprehensive oral evaluation on March 18, 2019, and January 13, 2020. The Plan covered this service two times within 3 years as a one-time exception, and your comprehensive oral evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation.
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: Favorable

We decided that the Plan has to pay for office visit services (CPT 99213) provided to the enrollee on February
9, 2021.
You asked the Plan to pay for the services. You say that the purpose of this visit was to have an ear obstruction
removed. The Plan denied your request. The Plan says that payment is not allowed, because the code was billed
without the required anatomical modifier.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
The services at issue in this case were rendered by a contract provider. The file does not show that the Plan
provided notice that the services would not be covered. Under Medicare rules, this means the services is
considered approved by the Plan. You should not be billed for anything over any applicable copayments.
Therefore, we decided that the Plan has to pay for office visit services (CPT 99213) provided to the enrollee on
February 9, 2021.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).

You asked the Plan to pre-approve the dental service. You say that the enrollee is missing tooth # 31. You also say that the enrollee was presented with a 3-unit bridge to restore function and aesthetics. The Plan denied your request. The Plan says the enrollee is not missing enough teeth to affect their chewing function.

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 dental service when the services are medically necessary and reasonable. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the dental service. Our reviewer says that the partial denture is not medically necessary. Our physician reviewer found there are no other missing teeth in the lower arch aside from the third molars. The reviewer found that there are more than eight posterior teeth in occlusion. The reviewer found that there would be adequate ability to chew. Although it would be reasonable to place a 3-unit bridge for teeth # 31 to 29, or place a partial denture in the lower arch to replace the one missing tooth, the amount of loss of chewing function is minimal. Therefore, the reviewer found that the requested partial denture does not rise to the level of medical necessity under the Plan.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for urology services (99204, 51798, 81000) provided on January 25, 2021, by an out of network (OON) provider.

You asked the Plan to pay for urology services. You say that the claims denied in error as the provider in in-network. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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 urology services (99204, 51798, 81000) provided on January 25, 2021, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan provided by an out-of-network provider on
February 17, 2021.

You asked the Plan to pay for the duplex scan. You say that authorization was not obtained at the time of
service, but the patient was admitted for medical necessity. You say that the claim should be considered for
retro authorization. The Plan denied your request. The Plan says prior authorization was required but 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 the duplex scan provided by an out-of-network
provider on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87633) provided January 7, 2021.

You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The Plan denied your request. The Plan says the CPT code billed is not covered.

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 87633 is not supported in the medical record. Specifically, per Local Coverage Article: Billing and Coding: MolDX: Multiplex NUCLEIC ACID Amplified Tests for Respiratory Viral Panels (A57579), tests that include more than 5 viral pathogens are non-covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87633) provided January 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on November 27, 2019.
You asked the Plan to pay for the radiology services. You say that because of the COVID-19 outbreak most insurance carriers allowed additional time to file a claim. The Plan denied your request. The Plan says the claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.
The record shows that a claim for the radiology services was not filed until January 22, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the radiology services provided on November 27, 2019.