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

We decided that the Plan does not have to pay for physician services provided to the enrollee out of network on
March 2, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 service 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 physician services provided to the enrollee out of network on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $40 copayment charged for an urgent care visit on April
25, 2020.
You asked the Plan to waive this copayment. You say that they did nothing to help your condition and you do
not believe you should have to pay the copayment. The Plan denied your request. The Plan says this copayment
was charged based on the claim submitted by the provider and the Plan contract agreement.
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 urgent care services. 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 $40 copayment charged for an urgent care visit
on April 25, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided
February 8, 2019 to February 21, 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. 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 inpatient skilled nursing facility (SNF) care provided February 8, 2019 to
February 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen system and portable oxygen concentrator provided from January 8, 2019 through February 7, 2019.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says that the claim was filed late.
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 these services was not filed until January 9, 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 the portable oxygen system and portable oxygen concentrator provided from January 8, 2019 through February 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Erleada tablets.
You asked the Plan to pre-approve Erleada tablets. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says Erleada tablets are not covered under the enrollee's
Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Erleada tablets.
Benefits for Erleada tablets may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on June 7, 2019.
You asked the Plan to pay for the presumptive and definitive drug testing. You say that this was medically necessary testing. The Plan denied your request. The Plan says there is no evidence that this provider is actively treating the enrollee for a specific medical condition. The provider did not submit records showing that this testing was ordered by a physician involved in the enrollee's care.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on June 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #9 and retainer crowns (D6740) for tooth #'s 8 & 10.
You asked the Plan to pre-approve the pontic and retainer crowns. You say that you need this treatment to ensure a healthy smile, and to improve masticatory function. The Plan denied your request. The Plan says the service is not medically necessary.
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 pontic and retainer crowns 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 pontic and retainer crowns. Our reviewer says that the pontic and retainer crowns do not meet the Plan's coverage criteria. Our physician reviewer found the provider has indicated on the treatment plan that tooth #5 is anticipated to be replaced by the use of a cantilever bridge. It is seen in the treatment notes, but not the claim form, that the Plan was to include #11 in the bridge as there is prior endodontic treatment of #10 making it a less reliable abutment. Our reviewer found that the size of the bridge is not of current concern in the determination under policy criteria as there is no clear issue that would preclude the use of a partial denture and that would absolutely require the use of fixed bridgework. Our physician reviewer also found that although the requested treatment may be feasible, under the Policy the reimbursement would be allowed for a removable appliance only. 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 pontic and retainer crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #9 and retainer crowns (D6740) for tooth #'s 8 & 10.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on February 6, 2019.
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says per Medicare guidelines, the evaluation and management procedure cannot be billed with modifier -59.
The Plan must follow Medicare rules. The rules state that modifier -59 is not appropriate to use with evaluation and management services. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Specifically, CPT code 99213 is an evaluation and management service. It is inappropriate to bill modifier -59 with evaluation and management services. Therefore, we decided that the Plan does not have to pay for the office visit (99213) provided on February 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 12, 2020.
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 professional component is not separately payable.
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately payable when furnished in different payment localities. We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different payment localities. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival flap procedure provided on February 25, 2020.
You asked the Plan to pay for the gingival flap procedures. You say that the services were necessary for dental
health. The Plan denied your request. The Plan says out-of-network dental services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
gingival flap procedure provided on February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on February 29, 2020.
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided were billed incorrectly.
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 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, and 81403 are not supported in the medical record. Specifically, CPT code 81479 should be reported for this service in addition to the approved DEX Z-Code entered adjacent in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on February 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power seat elevation system identified with code E2300.
You asked the Plan to pre-approve power seat elevation system. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is noncovered
because it is not primarily medical in nature.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of power seat elevation system have not been met. Therefore, we decided that the Plan does not have
to pre-approve power seat elevation system identified with code E2300.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care services (T1019).
You asked the Plan to pre-approve personal care services. You say that you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan says personal care services are not covered under your
Medicare Advantage benefit.
The Plan must follow Medicare rules. Medicare rules say that Custodial care is not covered.
We looked at the file, the Plan's contract and Medicare rules. Personal care services are considered custodial
care, which includes care that helps people with activities of daily living, like walking, getting in and out of
bed, bathing, dressing, eating, personal hygiene, and supervision of special diets and medications. Custodial
care and personal care services are not covered by Medicare. Therefore, we decided that the Plan does not have
to pre-approve personal care services (T1019).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services you received on March 29, 2020.
You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says the service were provided by an out-of-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by a provider who is in the vision network. We looked at the file and the Plan's rules. The requested provider is no in your vision plan's network. Out-of-network vision services are not covered. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the vision services you received on March 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a laminectomy provided on March 2,
2020.
You asked the Plan to waive the coinsurance for a laminectomy. You say that you checked beforehand that the
provider was in-network and disagree with the out-of-network 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 40%
coinsurance for out-of-network outpatient surgery, including services provided at hospital outpatient facilities
and ambulatory surgical centers.
The medical records show that you received a laminectomy on March 2, 2020 from an out-of-network
provider. Therefore, you are responsible to pay your share of the out-of-network charges. The total allowed
amount is $6,726.47 and 40% of that is $2,609.59.
You have been asked to pay the total coinsurance amount of $2,609.59 for a laminectomy. A laminectomy 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 coinsurance for a laminectomy provided
on March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation
submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests
are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for the drug testing services provided on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 3, 2020 to February
27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The
Plan says that the member's primary care physician did not refer these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for physician services provided on February 3, 2020
to February 27, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on February 17,
2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is no
eligible for payment for assistant surgeon service.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services
provided on February 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $225 copayment charged for ambulance transport provided on March 14, 2020.You asked the Plan to waive this copayment. You say that you did not authorize the calling of an ambulance.The Plan denied your request. The Plan says this copayment was charged based on the service provided and the Plan contract agreement.The rules say a plan must disclose to its enrolleesin clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $225 copayment for ambulance transport. 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 $225 copayment charged for ambulance transport provided on March 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 10, 2020 by an out of network (OON) provider.You asked the Plan to pay for the wound care services. You say that you would like reconsideration because this provider rendered medically necessary services in good faith.The Plan denied your request. The Plan says the utilization of network providers is required unless the plan pre-approves out-of-network services in non-emergent situations.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 January 10, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on November 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency for these 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 services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on June 13, 2019 to January 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or the facility for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided on June 13, 2019 to January 4, 2020 by an out of network (OON) provider.