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

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 17, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not approved in advance.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 had network providers available who could have provided 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 forthe medical services provided to the enrollee by an out-of-network provider on August 17, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe preventive procedure and two gingival irrigations provided on September 16, 2020.You asked the Plan to pay forthe preventive procedure and gingival irrigations. You say that these services were necessary for your treatment.The Plan denied your request. The Plan says gingival irrigation is not a covered benefit. The Plan also says that providers are receiving a separate monthly stipend for unspecified preventive procedures, and this claim was processed correctly.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 itemsor services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe preventive procedure and two gingival irrigations provided on September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on September 30, 2020.You asked the Plan to waive the copayment fora specialist visit. You say that you disagree with the charges because you saw a nurse practitioner not a physician.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 $40 copayment for each specialist visit. The medical records show that you had a specialist visit on September 30, 2020. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 enrolledin the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora specialist visit provided on September 30, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe endodontic therapy provided on September 16, 2020.You asked the Plan to pay forthe endodontic therapy. You say that you would like this service to be covered.The Plan denied your request. The Plan says your annual dental benefit maximum had been exhausted.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 Plan offers a $1,500 annual dental benefit maximum, less the cost-sharing you pay. The contract saysthat after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the September 16, 2020 date of service and your annual maximum benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe endodontic therapy provided on September 16, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services providedfrom May 18, 2020, through May 29, 2020.You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says with limited exceptions,while you are a member of our Plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Planauthorizes use of out-of-network 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.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physical therapy services.We found no exception that would require the Plan to pay for these services. Therefore, wedecided that the Plan does not have to pay for physical therapy services provided from May 18, 2020, through May 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a spectacle-fitting session (92340), spectacle frames
(V2020), and spectacle lenses (V2100) purchased on February 5, 2020.
You asked the Plan to pay for a spectacle-fitting session, spectacle frames, and spectacle lenses. You say that
the provided items/services were of high necessity. The Plan denied your request. The Plan says rules for
payment have not been met.
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 received from a Plan-contracted provider.
We looked at the file and the Plan's rules. The requested items/services were received from a non-contracted
provider. The Plan had network providers available who could have provided the items/services at issue in this
appeal. Based on this information, we decided that the Plan's rules for coverage of a spectacle-fitting session,
spectacle frames, and spectacle lenses have not been met. Therefore, we decided that the Plan does not have to
pay for a spectacle-fitting session (92340), spectacle frames (V2020), and spectacle lenses (V2100) purchased
on February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided on September 29, 2020.You asked the Plan to pay forintraoral periapical first radiographic image (D0220) and recement core bond crown (D2920). You say that you asked your dentist to get approval for the procedures.The Plan denied your request. The Plan says these services are not covered.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicareor the Plan.Therefore, we decided that the Plan does not have to pay forthe intraoral periapical first radiographic image (D0220) and recement core bond crown (D2920) provided on September 29, 2020
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from August 18, 2020,
through September 2, 2020.
You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or
emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for home health services provided from August 18, 2020, through
September 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 4, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.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. ThePlan did not pre-approve the physician's services.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's services provided on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on October 2, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you were told that this was a follow-up visit and you would not owe a copayment. 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 $15 copayment for physician/practitioner services, including doctor's office visits. You had an office visit on October 2, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $15 copayment. You have been asked to pay a $15 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on October 2, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on June 13, 2019.
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 claim was not filed timely.
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 October 21, 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 services rendered on June 13, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on November 4, 2020.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says the services were not approved in advance.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 had network providers available who could have provided 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 forthe medical services provided to you by an out-of-network provider on November 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lift chair purchased on August 4, 2020.You asked the Plan to pay forthese services. You say that you needed the chair after knee surgery.The Plandenied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pay forthe lift chair purchased on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from January 14, 2020, through March 3, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the for psychotherapy services. 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 psychotherapy services provided from January 14, 2020, through March 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe radiologic examination, chest (71045) provided April 16, 2020.You asked the Plan to pay forthe diagnostic services. You say that claim denied as duplicate in error. Please review and reprocess claim for reimbursement according to contract.The Plan denied your request. The Plan says exact duplicate/claim service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, we find that the based on the documentation provided, the plan previously paid for the appealed services on check dated 04/22/2020. Therefore, this is a duplicate. Based on this information, we decided that Medicare rules for coverage of the diagnostic services have not been met.Therefore, we decidedthat the Plan does not have to pay forthe radiologic examination, chest (71045) provided April 16, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroutpatient mental health services provided on August 11, 2020.You asked the Plan to waive the copayment foroutpatient mental health services. You say that you feel that the 3-4 minute conversation should not warrant a copayment.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 $35 copayment for outpatient mental health services. You have been asked to pay a $35 copayment for outpatient mental health services. Outpatient mental health services fall within the outpatient mental health 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 foroutpatient mental health servicesprovided on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foracupuncture services provided from August 6, 2020, to September 15, 2020.You asked the Plan to pay foracupuncture services. You say that benefits were checked and the enrollee does have acupuncture coverage.The Plan denied your request. The Plan says this provider is not supervised by any physician, PA or NP/CNS.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the provider is auxiliary personnel without supervision.Therefore, we decided that the Plan does not have to pay foracupuncture services provided from August 6, 2020, to September 15, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on October 14, 2020 by an out of network provider.You asked the Plan to pay forthe office visit. You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request 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 had network providers available who could have provided 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 forthe office visit provided on October 14, 2020 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from July 9, 2020 to July 11, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that the services provided were medically necessary.The Plan denied your request. The Plan says that clinical records do not support a reasonable expectation of a 2 midnight stay.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 reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department (ED) on July 9, 2020, due to 2 days of rectal bleeding. The patient was deemed too stable for the intensive care unit, so he was admitted for monitoring and further workup. The patient was discharged for outpatient follow up when considered medically stable on July 11, 2020. The review indicates that the record 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 been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from July 9, 2020 to July 11, 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/orsend 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital care (99233) and prolonged inpatient services (99356) provided on April 24, 2020.You asked the Plan to pay forhospital care and prolonged inpatient services. You say that the provided services were necessary.The Plan denied your request. The Plan says rules for payment have not been met.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forhospital care (99233) and prolonged inpatient services (99356) provided on April 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

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 20, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 had network providers available who could have provided 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 20, 2019.