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

We decided that the Plan does not have to pay for radiation treatment (77387, 77412) provided on July 22, 2019 by out of network provider. 
 
You asked the Plan to pay for radiation treatment. You say that you are requesting a review of the medical records for medical necessity and payment of claim. The Plan denied your request. The Plan says the provider is a non-network provider who does not work with the member's health plan. The Plan says that the member was referred by the physician, who also does not work with the member's plan. The Plan says the member's primary care physician did not refer for services. The health 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 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 radiation treatment (77387, 77412) provided on July 22, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered to you on February 18, 2020.
You asked the Plan to waive the copayment for these services. You say that when you had other insurance the copayment was only $10. 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 $45 copayment for each Medicare-covered specialist visit.
Review of the file shows that you received specialist services on February 18, 2020. You have been asked to pay a $45 copayment for these services. These services fall within the Medicare-covered specialist visit 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 specialist services rendered to you on February 18, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for an office visit (99214) and chemodenervation (64612) provided on December 12, 2019.
You asked the Plan to hold you harmless for the office visit and chemodenervation. You say that you would like reconsideration because this service was medically necessary to treat your condition. The Plan denied your request. The Plan says that a corrected claim is needed as this claim was not submitted with a required 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. You were referred for the office visit and chemodenervation. The doctor is a contract provider. The file does not show that the Plan provided notice that the office visit and chemodenervation would not be covered. Under Medicare rules, this means the office visit and chemodenervation is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for an office visit (99214) and chemodenervation (64612) provided on December 12, 2019.
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 pay for eyewear (V2220 and V2020) provided on June 27, 2018.
You asked the Plan to pay for eyewear. You say that you were not told there was a time limit to submit your request. The Plan denied your request. The Plan says your request for reimbursement was filed more than one year after the date of service.
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 eyewear was not filed until November 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 eyewear (V2220 and V2020) provided on June 27, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204), an initial comprehensive preventive
medicine evaluation (99387), a pelvic and clinical breast examination (G0101), and a pap smear (Q0091)
provided on July 16, 2019 by out of network provider.
You asked the Plan to pay for an office visit, an initial comprehensive preventive medicine evaluation, a pelvic
and clinical breast examination, and a pap smear. You say that the doctor informed the front desk secretary to
obtain prior authorization. You say for some unknown reason, there was a misconception, and the patient was
called in for treatment, prior to receiving authorization. You also say that Dr.  performed the
services assuming that the authorization was obtained by the secretary. The Plan denied your request. The Plan
says after four faxes and phone calls to the servicing provider to gain clinical documentation, none was received. The Plan says that  Dr.'s office claimed that no referral was received for treating the member. The Plan also says that all providers are required to furnish necessary information to the health plan when requested. The provider's staff is responsible for submitting information to the health plan for review and determination.
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 an office visit (99204), an initial comprehensive preventive medicine
evaluation (99387), a pelvic and clinical breast examination (G0101), and a pap smear (Q0091) provided on
July 16, 2019 by out of network provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for an x-ray (71045-26-59) provided on September 19, 2019. 
 
You asked the Plan to pay for an x-ray. You say that the billed service was correctly billed. The Plan denied your request. The Plan says that this was a duplicative service. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
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 an x-ray Our reviewer says that the records support the billing of 71045-26-59 by the provider on September 19, 2019. Our physician reviewer found a chest X-Ray was obtained on September 19, 2019 with an indication of "chest tube". Another chest Xray was obtained the same day with an indication of "post Chest tube removal". Modifier 59 is used to indicate a service that was independent from another service that was performed on the same day. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an x-ray have been met. Therefore, we decided that the Plan has to pay for an xray (71045-26-59) provided on September 19, 2019.  
 
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 pay for spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens (V2103) provided on June 12, 2019.
You asked the Plan to pay for the lens. You say that you disagreed with the processing of the claim. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. You had cataract surgery. You are asking for payment for lenses (V2103 (right and left) - Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens).
The medical record shows that these lenses were ordered for you following cataract surgery. The Plan approved payment for one (1) set of lenses. This decision is based on: two (2) - Local Coverage Article: Refractive Lenses - Policy Article (A52499), which states: For beneficiaries with pseudophakia, coverage is limited to one pair of eyeglasses or contact lenses after each cataract surgery with insertion of an IOL. You are asking for payment for 2 additional sets of lenses (V2103 (right and left) - Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens). We are still unable to approve your request. The medical record shows that these lenses were ordered for you following cataract surgery. Your 2019 EOC states that you have coverage for one pair of eyeglasses or contact lenses after each cataract surgery, with $0 copayment. The Plan has approved payment for one set of lenses. Your request for additional lenses does not meet the rules for approval because it exceeds the benefit of your Medicare and the plan. Your request remains denied. Therefore, we decided that the Plan does not have to pay for spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens (V2103) provided on June 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion consult to be provided by out of network provider.
You asked the Plan to pre-approve a specialist office visit. You say that you were diagnosed with lupus. You say that you were misdiagnosed and would like to see the Dr. for a second consult. The Plan denied your request. The Plan says the Dr. is out-of-network. The Plan says that there are in-network providers available.
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 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. 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 second opinion consult to be provided by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided to the enrollee
from October 10, 2019 to October 11, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee had significant healthcare
needs that could not have been safely managed at a lower level of care. The Plan denied your request. The Plan
says the information provided does not warrant an inpatient level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our physician
reviewer found that the enrollee was brought to the emergency department after being involved in a motor
vehicle accident. In the ambulance he had a tonic-clonic seizure and was treated with Versed. in the emergency
department, he was amnestic with stable vital signs. A computed tomography (CT) of the abdomen and pelvis
was normal, a CT chest revealed an age indeterminate T8 compression fracture and left rib fractures 5,6, and 7;
and a CT cervical spine was normal. The CT of the brain revealed no acute intracranial process with an old
subdural hygroma. The enrollee was admitted and had no further seizures. He was evaluated by physical
therapy, and was felt stable for discharge. The records did not show that at the time of inpatient admission the
admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or
observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided to the enrollee from October 10, 2019
to October 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on November 18, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you do not understand why this was denied because part of your tooth had fractured off. The Plan denied your request. The Plan says the service exceeds the frequency limitation in your benefit 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, exams are limited to two procedures per calendar year. The record shows that you received problem focused limited oral evaluations on September 9, 2019 and October 7, 2019 and your exams benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One services.
You asked the Plan to pre-approve the Synvisc-One services. You say that the requested injection services are medically necessary and coverage should be reconsidered. The appellant says that they do not carry Orthovisc and Monovisc. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
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 Synvisc-One services. Our reviewer says that the criteria for coverage of Synvisc-One services have not been met. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The enrollee has not tried and failed the required drugs. The documentation does not support that Orthovisc and Monovisc would likely be less effective or have adverse effects for the 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 Synvisc-One services have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99215), an injection beneath the skin or into
muscle for therapy, diagnosis, or prevention (96372), and an injection of ketorolac tromethamine (J1885)
provided on September 3, 2019 by out of network provider.
You asked the Plan to pay for an office visit and injections. You say that you are appealing the denied claim as
the notes support the need for service. The Plan denied your request. The Plan says the rendering provider is a non-participating provider. There is not a referring provider. Our plan did not authorize any services. There are multiple in-network providers within 30 miles of the members residence that could have rendered the services. The services are not considered urgent/emergent in nature.
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 an office visit (99215), an injection beneath the
skin or into muscle for therapy, diagnosis, or prevention (96372), and an injection of ketorolac tromethamine
(J1885) provided on September 3, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for an x-ray procedure on a vein or a lymph
system (01930) provided on August 28, 2019 by out of network provider.
You asked the Plan to pay for anesthesia. You say that you are appealing the claim payment denial for services
rendered to the Plan's member on date of service August 28, 2019. The Plan denied your request. The Plan says
the attending provider is a non-participating provider. The plan did not authorize any services
for Profit Anesthesia Consultants. The services are not considered urgent/emergent in nature. Services rendered
by non-participating providers require prior authorization as outlined in the enrollee's EOC.
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 anesthesia for an x-ray procedure on a vein or a
lymph system (01930) provided on August 28, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.
You asked the Plan to pre-approve a specialist office visit. You say that you would like to see Dr. because he did your surgery. The Plan denied your request. The Plan says there are in-network providers available for this office visit.
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 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. 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 the medical services to be provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Typhoid vaccine and administration (90472 and 90691) provided on August 6, 2019.
You asked the Plan to pay for the Typhoid vaccine. You say that you were traveling and your doctor felt it necessary for you to receive the immunization. The Plan denied your request. The Plan says the submitted claim shows the you received the services as a preventative measure, which means the vaccination is not covered under your Plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Typhoid vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Typhoid vaccine. Therefore, we decided that the Plan does not have to pay for a Typhoid vaccine and administration (90472 and 90691) provided on August 6, 2019.
Benefits for the Typhoid vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.