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

We decided that the Plan does not have to pay for an outpatient hospital physician visit provided on January 22, 2018.
You asked the Plan to pay for physician visit. You say that you made your best efforts to submit this claim in a
timely manner. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because this claim was not submitted within the timely filing limit.
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 physician visit was not filed until October 1, 2019. 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 an outpatient hospital physician visit provided on January 22, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 19, 2019 by an out of network (OON) provider.You asked the Plan to pay foroffice services. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial ofpayment for these services is correct, because this provider is out-of-network with the Plan and 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 forthe medical services provided on November 19, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that you were not aware of the requirement of obtaining a prior authorization. The Plan denied your request. The Plan says there is no network deficiency for the 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 OON services. Therefore, we decided that the Plan does not have to pay for the lab services provided to on November 22, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a chest x-ray (71045) provided on November 25, 2019.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because the member
had multiple exams on this date of service. The Plan denied your request. The Plan says that this is a duplicate
of a claim which was processed and paid.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied.
We find that CPT code 71045 26 59 is supported in the record. Specifically, this service was rendered by a
different provider than that of the approved and paid claim. Additionally, an appropriate modifier has been
used to indicate that this was a distinct procedural service. Based on this information, we decided that Medicare
rules for coverage of the chest x-ray have been met. Therefore, we decided that the Plan has to pay for a chest
x-ray (71045) provided on November 25, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency care services provided on September 29, 2018.
You asked the Plan to pay for emergency care services. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this claim was not submitted within the timely filing limit.
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 emergency care services was not filed until October 31, 2019. 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 emergency care services provided on September 29, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forphysician services provided on January 8, 2019.You asked the Plan to waive the coinsurance forphysician services. You say that you think you consulted the Plan prior to seeing the doctor. You say that you were informed you were covered.The Plan denied your request. The Plan says the coinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate termsall cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% of the Medicare-allowed amount for each out-of-network primary care provider visit for Medicare-covered services.You have been asked to pay $97.85, which is 50% of the allowed amount for physician services. The allowed amount is $195.70 (50% x $195.70 = $97.85). Physician services falls within the "Physician/Practitioner services, including doctor's office visits"benefit category. The records show that the provider is out-of-network. 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 forphysician services provided on January 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the documentation does
not support that the enrollee has a history of osteoporosis-related fracture. The Plan also says that the
documentation does not support that the enrollee has failed or has a contraindication to Zoledronic Acid.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Prolia. Our reviewer says that the
criteria coverage has not been met. Our physician reviewer found the records do not show that the enrollee has
a history of osteoporosis-related fracture. Our reviewer found that the clinical documentation does not support
that Zoledronic Acid has been tried and failed. Our physician reviewer also found that the clinical
documentation does not support that Zoledronic Acid would likely be less effective, and/or would likely have
adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) and prophylaxis (D1110) provided on December 9, 2019.You asked the Plan to pay forthe dental services. You say that you just learned that your dental rider was cancelled on November 30, 2019 due to non-payment. You say that when you signed up for the dental rider in September 2019, you paid for the first month and agreed that future payments would be auto-deducted from your account by the Plan. You say that you were never notified that your policy had been cancelled. You also say that you would like your dental rider to be re-instated back to November 30, 2019.The Plan denied your request. The Plan says you were not enrolled in the dental rider at the time you received these services. The Plan also says you were sent notification letters advising that your premium payment would need to be received by November 30, 2019 to stop the dis-enrollment.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. The record shows that the Plan sent letters onOctober 8, 2019 and November 8, 2019advising that your premium payment had not been received.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) and prophylaxis (D1110) provided on December 9, 2019.
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for the Part B drug. We decided that the Plan does not have to waive the coinsurance for the Part B drug.
You asked the Plan to waive the coinsurance for the Part B drug. You say that the application of the cream should be considered a part of the procedure. You say you should not be charged for it. The Plan says that you have been charged the correct cost sharing amount.
We decided that the Plan has to reduce the coinsurance for the Part B drug.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that the coinsurance amount was not calculated correctly. The Explanation of Benefits shows the allowed amount is $789.89. ($789.89 x 20% = $157.98.
The Plan says that you must pay $158.43 for the Part B drug. Based on the plan contract, however, you cannot be asked to pay more than $157.98 for the Part B drug. Therefore, we decided that the Plan has to reduce the coinsurance for the Part B drug from $158.43 to $157.98.
We also decided that the Plan does not have to waive the coinsurance for the Part B drug.
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 20% for the Part B drug. Therefore, we decided that the Plan does not have to waive the coinsurance for the Part B drug.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on October 17, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 domiciliary, rest home visit provided on October 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation with limited field of view provided on November 11, 2019.You asked the Plan to pay for the cone beam CT capture and interpretation. You say that this x-ray was the only way to determine how bad the infection on tooth #19 was.The Plan denied your request. The Plan says this service is not a covered benefit.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 cone beam CT capture and interpretation with limited field of view provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 29, 2019 by an out of network (OON) provider.You asked the Plan to pay for the office visit. You say that you never saw this provider on this date.The Plan denied your request. The Plan says the services received are not a covered benefit.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.Review of the file shows that you did receive an office visit on April 29, 2019 for a medication refill. 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 office visit provided on April 29, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction services received on December 13, 2019.
You asked the Plan to pay for the services. You say that you were seen on December 13, 2019 for an
examination prior to having cataract surgery done. The Plan denied your request. The Plan says this is not a
covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover eye refraction.
The services you asked the Plan to pay for are considered eye refraction. Therefore, we decided that the Plan
does not have to pay for eye refraction services received on December 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on September 18, 2019.You asked the Plan to waive the copayment for an MRI. You say that you were told that you would not owe a copayment because this was related to a car accident.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 $300 copayment for MRI's. You have been asked to pay a $300 copayment for an MRI. An MRI 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 an MRI provided on September 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Visco-3 (J7321).
You asked the Plan to pre-approve the Visco-3. You say that the Visco-3 is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says the member does not meet step-therapy exception criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Visco-3. Our reviewer says that the member has not tried and failed a trial of Orthovisc and Monovisc. Our physician reviewer found the record does not support that Monovisc and Orthovisc would likely be less effective or have adverse effects.
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 Visco-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Visco-3 (J7321).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 80159, and 80173 provided on August 26, 2019.
You asked the Plan to pay for the laboratory 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 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 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical record. Specifically, the documentation submitted did not support that Carbamazepine; free testing, Levetiracetam testing, Topiramate testing, Digoxin; total testing, Clozapine testing, or Haloperidol testing were performed. Blood specimen collection is by venipuncture, however, the lab requisition states a urine specimen was collected; therefore, the billed services cannot be verified. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 80159, and 80173 provided on August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided by Connection CareGroup on November 6, 2019.You asked the Plan to pay forthe knee orthoses (L1833) and suspension sleeves (L2397). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says services are misrepresented.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not support medical necessity of the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthoses (L1833) and suspension sleeves (L2397) have not been met.Therefore, we decided that the Plan does not have to pay forthe knee orthoses and suspension sleeves provided by Connection CareGroup on November 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from June 22, 2019 to June 28, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says that during this time, the enrollee received services such as assessment of pain, assessment oxygen saturation, administration of oral medications, and the administration of nebulized breathing treatments. The Plan also says that these are not inherently complex services that require a registered nurse to safely perform.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from June 22, 2019 to June 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for laboratory services and does not have to waive the coinsurance for a Medicare Part B drug injection provided from September 11, 2019 to September 20, 2019.
You asked the Plan to waive the copayments for laboratory services and does not have to waive the coinsurance for a Medicare Part B drug injection. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for laboratory services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received laboratory services on September 11, 2019. Therefore, you are responsible to pay the $10 copayment. You received laboratory services on September 20, 2019. Therefore, you are responsible to pay the allowed amount of $9.39, which is less than the $10 copayment. You received a Medicare Part B drug injection on September 20, 2019. The allowed amount is $1,146.24 and 20% of that is $229.25.