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 you by an out-of-network provider on August 3, 2020.You asked the Plan to pay forthe 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 forthe medical services provided to you by an out-of-network provider on August 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364)
provided on October 13, 2020.
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you believe this
service should be covered. The Plan denied your request. The Plan says this service is not a covered benefit.
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 for the cone
beam CT capture and interpretation (D0364) provided on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on July 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.
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 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 lab services provided on July 29, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on October 1, 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 services are not covered from an out-of-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only from a network provider. We looked at the file and the Plan's rules. The file shows that you received hearing aids from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on October 1, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for interrogation device evaluation(s) (remote),
up to 90 days; single, dual, or multiple lead implantable defibrillator system with interim analysis, review(s)
and report(s) by a physician or other qualified health care professional (93295) provided on September 21,
2020.
You asked the Plan to waive the copayment for a pacemaker evaluation. You say that you should not have to
pay the copayment. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50
copayment for outpatient diagnostic tests.
You have been asked to pay a $50 copayment for a pacemaker evaluation. A pacemaker evaluation falls within
the outpatient diagnostic tests 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
interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead implantable
defibrillator system with interim analysis, review(s) and report(s) by a physician or other qualified health care
professional (93295) provided on September 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal evaluation (D0180) provided on August 20, 2020.
You asked the Plan to pay for the dental service. You say that the provider gave you a treatment plan of just under $2,000. You say that you contacted your previous periodontist for a second opinion. You say that the provider is running a dishonest money making operation. You also say that you are on a very limited income. The Plan denied your request. The Plan says 1 comprehensive or periodontal evaluation is covered every 3 years. The Plan also says that the benefit has 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 benefit has been exhausted. The record shows that the Plan reimbursed you for a comprehensive oral evaluation that you received on July 30, 2020. Therefore, we decided that the Plan does not have to pay for the periodontal evaluation (D0180) provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided on October 8, 2019.You asked the Plan to pay forthe dental services. You say that you were not informed by the Plan you needed to convert to a dental special plan.The Plan denied your request. The Plan says these services are not a covered benefit.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 dental services provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient office visit (99203) therapeutic, prophylactic, or diagnostic injection (96372) injection, methylprednisolone acetate (J1030) injection, dexamethasone sodiumphosphate (J1100) provided September 10, 2020.You asked the Plan to waive the copayment forthe office visit. You say that this is being billed as a PCP visit but this was an ER visit.The Plan denied your request. The Plan says the plan verified that the claim was processed and the correct copayment was applied per the Evidence of Coverage.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 20% coinsurance for Medicare Part B drugs excluding chemotherapy drugs and 50% coinsurance of the Medicare allowed amount after the $950 yearly out of network deductible for Physician/Practitioner services, including doctor's office visits and Medicare Part B prescription drugs. You have been asked to pay $93.70 for the office visit. The office visit falls within the Physician/Practitioner services, including doctor's office visits and Medicare Part B prescription drugs benefit categories. 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 outpatient office visit (99203) therapeutic, prophylactic, or diagnostic injection (96372) injection, methylprednisolone acetate (J1030) injection, dexamethasone sodium phosphate (J1100) provided September 10, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCervical Radiofrequency Lesioning Right Side.You asked the Plan to pre-approvethe service. You say that the service is necessary.The Plan denied your request. The Plan says the enrollee's history of neck pain that travels down their arm and other tests do not show that this type of shot for pain would beof help to 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 service. Our physician reviewer found the criteria for cervical ablation are not met. The enrollee has radicular pain going down their arm. This is a contraindication to ablation. The ablation is not needed.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 service have not been met.Therefore, we decided that the Plan does not have to pre-approveCervical Radiofrequency Lesioning Right Side.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services (0012M) provided on September 9, 2020.You asked the Plan to pay forthe lab services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not pre-authorized or emergent. There were network providers available.Medicare rules say that plans can require enrollees to getcare 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 lab services (0012M) provided on September 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe folding wheeled walker provided on September 30, 2020 by an out of network provider.You asked the Plan to pay forthe folding wheeled walker. 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, outof area urgent care and pre-approved care.Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary.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 items at issue in this appeal. The Plan did not pre-approve the item at issue. Payment for this service would have been included under the global facility claim. Payment to you for this service is the responsibility of the facility or hospital. We found no exception that would require the Plan to pay for this item.Therefore, we decided that the Plan does not have to pay forthe folding wheeled walker provided on September 30,2020 by an out of network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you received on July 16, 2020.
You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says this is not a covered
benefit.
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 during a routine exam.
We looked at the file and the Plan's rules. The records do not show that the eye refraction was provided during
a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the refraction
have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction you received
on July 16, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance services (A0427 and A0425) provided on September 24,
2020.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because the
records show why there would be concern for the member's health and safety. The Plan denied your request.
The Plan says that the ambulance services were not medically necessary.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same rules.
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 ambulance services. Our reviewer says
that the member's presenting symptoms meet prudent layperson criteria for emergency care. Our physician
reviewer found with blood sugar at this level with acute illness and potential dangers of driving with markedly
elevated blood sugar to this degree, it was reasonable for a lay person to decide that ambulance transport is best
and indicated.
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 ambulance services have been met. Therefore, we decided that the Plan has
to pay for ambulance services (A0427 and A0425) provided on September 24, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient hospital services provided on March 9, 2020, by an out-of-network (OON) provider.You asked the Plan to pay foroutpatient hospital services. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior 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 had network providers available who could have provided 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 foroutpatient hospital services provided on March 9, 2020, by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thoracic epidural injection (CPT Code 62321).
You asked the Plan to pre-approve the injection. You say that the services are necessary. The Plan denied your
request. The Plan says in order to qualify for this injection you need to have shooting pain caused by the
presence of spinal stenosis (narrowing), disc herniation or wear and tear changes in the vertebrae per your
exam and imaging. The Plan states these findings were not noted and you also have not tried any physical
therapy, chiropractic care or home exercise program for your pain. The Plan states there is no explanation
stating why you cannot try any of these options.
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 pre-approve the injection. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found per the coverage criteria: Epidural Steroid Injection for chronic pain must have all of the
following: Persistent radicular pain has been caused by spinal stenosis, disc herniation or degenerative changes
in the vertebrae, as confirmed by physical exam and imaging; pain interferes with ADLs and has lasted for at
least 3 months; member has failed to respond to conservative therapy including all of the following: 6 weeks
chiropractic, physical therapy or prescribed home exercise program; NSAID 3 weeks or NSAID
contraindicated or not tolerated; 6 weeks activity modification. Our physician reviewer states that in this case,
there is no radiculopathy and no documentation of at least 6 weeks of chiropractic, physical therapy or
prescribed home exercise program. The requested thoracic epidural steroid injection is not medically necessary
or reasonable.
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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve thoracic epidural injection (CPT Code 62321).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on August 25, 2020.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says
authorization is required for non-contracted 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
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 diagnostic radiology services provided on August 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 16, 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 there is no valid physician order.
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 laboratory services rendered on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray exam of the spine (72082) and the office visit (99203) provided on August 17, 2020.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy or byMedicare.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe x-ray exam of the spine (72082) and the office visit (99203) provided on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the new patient office visit (99204) provided on August 17, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service is not payable because another
evaluation and management exam was found in the member's claim history within a three year period.
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, the CPT Code Manual definition of code 99204 is a new patient office visit.
We find that CPT code 99204 is not supported in the medical record. Specifically, Medicare rules say that you
interpret the phrase "new patient" to mean one who has not received any professional services from the
physician or another physician of the same specialty who belongs to the same group practice, within the past
three years. A review of the claims history provided shows that the billing physician treated this enrollee during
a hospital stay from October 22, 2019, to November 1, 2019. As such, the rules for billing a "new patient" E/M
code have not been met. Based on this information, we decided that Medicare rules for coverage of this service
have not been met. Therefore, we decided that the Plan does not have to pay for the new patient office visit
(99204) provided on August 17, 2020.