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

We decided that the Plan does not have to pay for the medical services provided on March 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the out of network medical services. You say that authorization was not required for the services in dispute. The Plan denied your request. The Plan says the provider is non-network with the enrollee's health plan and the enrollee self-directed. The Plan says that it was not medically necessary for the enrollee to receive care out of network and that the services in dispute were not pre-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 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 March 29, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression device appliances provided on October 2, 2019.
You asked the Plan to pay for pneumatic compression device appliances. You say that the appliances were used post-surgery to prevent a thromboembolic event. The Plan denied your request. The Plan says the billed supply code cannot be supported.
The Plan follows Medicare rules. The rules state items used for preventative functions are not covered. 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. Therefore, we decided that the Plan does not have to pay for pneumatic compression device appliances provided on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe medical eye exam provided on January 24, 2019.You asked the Plan to waive the copayment forthe medical eye exam. You say that you feel the copayment is too high. The Plan denied your request. The Plan says the claim was reprocessed with a $40 member copayment.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 exams to diagnose and treat diseases and conditions of the eye for all other Medicare-covered vision services. You have been asked to pay a $40 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The record shows diagnoses of keratitis, age-related nuclear cataract, and dry eye syndrome which makes the exam medical in nature.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 forthe medical eye exam provided on January 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on November 29, 2019.
You asked the Plan to waive the copayment for the breast ultrasound. You say that the ultrasound should also be covered as preventive. The Plan denied your request. The Plan says the copayment 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 $100 copayment for diagnostic radiology. You have been asked to pay $61.67, which is less than the standard $100 copayment for the breast ultrasound. The breast ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the breast ultrasound provided on November 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services you received at a VA facility from January 17, 2019, to September 4, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says payment cannot be made for services rendered at this type of facility.The Plan must follow Medicare rules. Medicare rules say that payments may not be made to any Federal provider of services for any item or service that such provider is obligated by law, or contract with the United States, to render at public expense.We looked at the file and Medicare rules. The requested services were provided to you at a VA facility. Medicare rules do not allow payment to be made for services rendered at a VA facility. 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 forthe services you received at a VA facility from January 17, 2019, to September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided on May 2, 2019.You asked the Plan to pay fordrug test. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of paymentfor this service is correct, because the laboratory requisition form submitted is not valid.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing provided on May 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forintraoral -periapical each additional radiographic image (D0230 x 2) provided on November 4, 2019.You asked the Plan to pay forthe dental services. You say that this is the only option given to you by your dentist.The Plan denied your request. The Plan says this is the only option given to you by your dentist.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.You exhausted your benefit frequency limit. Your EOC clearly states, intraoral x-rays -Frequency/Limitations -One set per calendar year.Therefore, we decided that the Plan does not have to pay forintraoral -periapical each additional radiographic image (D0230 x 2) provided on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 30, 2019 to by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating 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 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 November 30, 2019 to by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99310) provided by out
of network (OON) provider on July 1, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment of the services provided. The Plan denied your request. The Plan says the services were
provided by an out of network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan
does not have to pay for the subsequent nursing facility care (99310) provided by the out of network (OON)
provider on July 1, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pay forhome health services provided to the enrollee from June 26, 2019 to August 23, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysa corrected claim must be submitted with a treatment authorization code.The Plan must follow Medicare rules. Medicare rules say that home health claims require a treatment authorization code.The case file did not contain a valid treatment authorization code. 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 forhome health services provided to the enrollee from June 26, 2019 to August 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on May 16, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe records do not support the service billed.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 Plandoes not haveto pay fordrug testing services provided to the enrollee on May 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Uloric 40mg tablet medication.You asked the Plan to pre-approvethis medication.You say that you are requesting a reconsideration of the Plan's denial as the patient has Gout and this medication works well to control hersymptoms.The Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual policy.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by MedicarePart B.Therefore, we decided that the Plan does not have to pre-approvethe Uloric 40mg tablet medication.Benefits for this medicationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for3 periapical x-rays (D0220), the bitewing x-rays (D0274), the panoramic x-ray (D0330), and the limited oral evaluation (D0140) provided from October 23, 2019 to November 11, 2019.You asked the Plan to pay for2 additional periapical x-rays. You say that you asked the previous dentist office to send your x-rays to another doctor for a second opinion. You say that you were advised they would not do that. You also say that you needed to get new x-rays done with the new dentist in order to get a second opinion.The Plan denied your request. The Plan says the frequency limit for periapical x-rays is once per calendar year. The Plan also says that the frequency limit has been exceeded.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coveragerules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage and periapical x-rays are a covered service, the frequency limit has been exceed with the approval for 1 periapical x-ray for date of service October 23, 2019.Therefore, we decided that the Plan does not have to pay for3 periapical x-rays (D0220), the bitewing x-rays (D0274), the panoramic x-ray (D0330), and the limited oral evaluation (D0140) provided from October 23, 2019 to November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 7, 2019.
You asked the Plan to pay for the assembly and operation of a pump. You say that it takes 30 minutes to set up the machine and the perfusionist is required to be in the operating room for the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of a pump have not been met. Specifically, payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital observation care services (99226) provided on June 24, 2018.
You asked the Plan to pay for the subsequent hospital observation care services. You say that your physician provided medically necessary services to the enrollee in good faith and you should not be penalized for delays in the receipt of information from the facility. The Plan denied your request. The Plan says the claim was filed after the timely filing limitations.
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 subsequent hospital observation care services was not filed until January 14, 2020. 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 subsequent hospital observation care services (99226) provided on June 24, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio for the enrollee.
You asked the Plan to pre-approve Entyvio. The Plan denied your request. The Plan says that they did not
receive documentation supporting the medical necessity for a step therapy exception.
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 Entyvio. Our reviewer says that
Entyvio is not medically reasonable and necessary for the enrollee in this case. There is no documentation that
Stelara has been tried and failed. The documentation does not support that Stelara would likely be less
effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found
that the enrollee's condition does not meet step therapy criteria for Entyvio.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have
to pre-approve Entyvio for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that you were not aware of the requirement for prior authorization and conduct the testing ordered by the referring provider. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 14, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Orthovisc injections provided from July 19, 2019 to August 1, 2019.
You asked the Plan to waive the coinsurance for the injections. You say that you would have declined the treatment if you knew you would be paying a copay over $100 for each shot. The Plan denied your request. The Plan says that the claims processed 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Medicare Part B prescription drugs 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 coinsurance for the Orthovisc injections provided from July 19, 2019 to August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forurgently needed services provided on September 11, 2019.You asked the Plan to waive the copayment forurgently needed services. 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 $55 copayment for urgently needed services. You have been asked to pay a $55 copayment for urgently needed services. Urgently needed services fall within the urgently needed services 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 forurgently needed services provided by on September 11, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora diagnostic colonoscopy provided on November 6, 2019.You asked the Plan to waive the copayment fora diagnostic colonoscopy. You say that you disagree with the charges due to a false positive Cologaurd test.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 $200 copayment for each outpatient ambulatory surgical center visit.You had a colonoscopy on November 6, 2019 due to a positive Cologuard test.  Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $200 copayment. You have been asked to pay a $200 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 fora diagnostic colonoscopy provided on November 6, 2019.