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

We decided that the Plan does not have to waive the copayment forthe office visit received on February 14, 2020.You asked the Plan to waive the copayment forthe office visit. You say that you feel this service should be covered.The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.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 podiatry services. You have been asked to pay a $45 copayment for the podiatry office visit. The office visit falls within the podiatry 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 forthe office visit received on February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 24, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that you believe that authorization should be waived for this service.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 careand pre-approved care.The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on June 24, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe sinus augmentation (D4266), the guided tissue regeneration (D), nitrous oxide sedation (D and the personal protective equipment (D1999) provided on July 9, 2020.You asked the Plan to pay forthe dental services. You say that you need to get implants. You say that your remaining teeth and jaw will not allow for a denture. You say that the implants will allow for a denture. You also say that the services should be covered because it is your only option to get proper function back.The Plan denied your request. The Plan says the sinus augmentation is not listed as a covered service. The Plansays that guided tissue regeneration is not a covered service. The Plan also says that nitrous oxide sedation is not a covered service. The Plan also says that the $20 charge for personal protective equipment is not covered as it is not listed as a covered service either.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 forthe sinus augmentation (D4266), the guided tissue regeneration (D), nitrous oxide sedation (D and the personal protective equipment (D1999) provided on July 9, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waivethe $1250 copayment charged for inpatient care provided from August 22, 2020, to September 2, 2020 and the $150 copayment for a computed tomography (CT) scan provided on September 11, 2020.You asked the Plan to waivethese copayments. You say that these copayments should be waived because you had Covid-19.The Plan denied your request. The Plan says these copayments were charged based on the services provided 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 cost share for days 1 to 5 of an inpatient stay and for outpatient diagnostic services. In this case, you had an inpatient hospital stay for Covid-19 and an outpatient CT scan afterward. According to Medicare guidance, Medicare Advantage plans may waive or reduce cost sharing for COVID-19-related treatments, but this is not required. Medicare waived the cost share for Covid-19 testing and for Covid-19 vaccines. The Plans are still required to pay for services such as inpatient hospital states and outpatient diagnostics. The Plan has paid its share of the cost for the services provided. 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 waivethe $1250 copayment charged for inpatient care provided from August 22, 2020, to September 2, 2020 and the $150 copayment for a computed tomography (CT) scan provided on September 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) provided on August 17, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe periodic oral evaluation. You say that you were not aware that you needed to verify the dentist you were seeing was in-network.The Plan denied your request. The Plan says there is no coverage for services rendered by an OON 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. The Plan covers the periodic oral evaluation when provided by an in-network provider.We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the periodic oral evaluation have not been met.Specifically, the services were not provided by an in-network provider.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) provided on August 17, 2020, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that IRF care is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of LTACH services.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient does not require any services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility.

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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe additional mileage services received on July 27, 2020.You asked the Plan to pay forthe additional mileage services. You say that you feel this should be covered.The Plan denied your request. The Plan says the mileage difference is the responsibility of the enrollee.Medicare pays for ambulance services only to the nearest appropriate facility. The Plan follows the same rules. We looked at the file and Medicare rules. Review of the file shows that the nearest hospital was approximately 6.3 miles from your residence. You were taken to a different hospital that was approximately 10.8 miles from your residence. Since you were not brought to the nearest hospital facility, you are responsible for the difference in mileage. Based on this information, we decided that Medicare rules for coverage of the additional mileage services have not been met. Therefore, we decided that the Plan does not have to pay forthe additional mileage services received on July 27, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
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 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 the medical services provided on September 4, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forlaboratory services provided to the enrollee on July 28, 2020.You asked the Planto pay forthe services. You say that this should be reconsidered.The Plandenied your request. The Plansaysthere is a missing/incomplete/invalid principal diagnosis.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found diagnosis code D75.81 is the only diagnosis code listed on the claim. Per the ICD-10 Coding Manual, there are notes for this code indicating to "code first the underlying disorder", and "use additional code, if applicable". As there are no other codes listed on this claim to indicate an underlying disorder, the denial is appropriate. The review has determined that the services at issue in this case are not medically reasonable or necessary.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 services have not been met.Therefore, we decided that the Plandoes not haveto pay forlaboratory services provided to the enrollee on July 28, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 8, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that the provider shouldn't be punished for the facility's failure to get authorization.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. The Plan states that neither the provider of these services nor the facility where the member was receiving care are Plan providers.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.You are not a network provider with the Plan.  The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on May 8, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fororthotics (L1833, L1971, L2397, L3170) provided on August 4, 2020.You asked the Plan to pay fororthotics. You say that these items were medically necessary.The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the physician.The Plan must follow Medicare rules. Medicare rulessay that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. 
Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fororthotics (L1833, L1971, L2397, L3170) provided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the medical services. You say that these medically necessary services were provided in good faith. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
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 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 the medical services provided on August 7, 2020 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc injection for the enrollee.
You asked the Plan to pre-approve the. You say that this is medically necessary. The Plan denied your request. The Plan says this medication is to be supplied by a commercial pharmacy and not a buy and bill from the provider's office.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Monovisc injection for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePembrolizumab.You asked the Plan to pre-approvePembrolizumab. You say that this drug is medically necessary for this patient.The Plan denied your request. The Plan says coverage criteria are not met for this drug.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Pembrolizumab. Our reviewer says that this drug is not medically necessary for this patient. Our physician reviewer found this drug is not the accepted first line treatment for patients without the epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) wild type.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Pembrolizumab have not been met.Therefore, we decided that the Plan does not have to pre-approvePembrolizumab.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 6, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that these services were provided in good faith and the doctor shouldn't be penalized for the facility's failure to get authorization.The Plandenied your request. The Plan says unauthorized, non-plan care is not covered.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-networkproviders 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 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 July 6, 2020 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ophthalmology services provided on September 24, 2020 to September 29, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe ophthalmology services. You say that you saw this doctor before your changed your insurance.  You said that this doctor's office assumed they were still in network on this date of service.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. The Plan says that neither the provider of service nor the referring provider is a Plan provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.The Plan cannot be held responsible for incorrect information provided to youby an out-of-network provider. Therefore, we decided that the Plan does not have to pay forthe ophthalmology services provided on September 24, 2020 to September 29, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services (86077) provided July 20, 2020.
You asked the Plan to pay for the pathology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the allowable amount.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 86077 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the pathology services have not been met. Therefore, we decided that the Plan does not have to pay for pathology services (86077) provided July 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveIVIG for the enrollee.You asked the Plan to pre-approveIVIG. You say that IVIG is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IVIG. Our reviewer says that Medicare coverage criteria are not met. Ourphysician reviewer found the referenced LCD is silent for autoimmune hemolytic anemia. However, per "per Am J hematology 44(4)Dec 1993"it is stated that IVIG cannot be recommendedas standard therapy for autoimmune hemolytic anemia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IVIG have not been met.Therefore, we decided that the Plan does not have to pre-approveIVIG for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to process the claim for the services provided on January 15, 2020.
You asked the Plan to process the claim for the services. You say that the claim should be paid. The Plan denied your request. The Plan says that the claim was not filed timely.
The Plan must follow Medicare rules. Medicare rules say that claims for services furnished on or after January 1, 2010, must be filed no later than the close of the period ending 1 calendar year after the date of service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. The services were received on January 15, 2020, and according to Medicare rules, claims for services furnished on or after January 1, 2010, must be filed no later than the close of the period ending 1 calendar year after the date of service. Therefore, the claim was filed timely and must be processed by the Plan. Therefore, we decided that the Plan has to process the claim for the services provided on January 15, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.