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

We decided that the Plandoes not haveto pre-approvea referral for a second opinion at an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no indication that in-network providers are not capable of providing for the enrollee's needs.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  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 referral. Our reviewer says that the requested referral is not medically reasonable or necessary. Our physician reviewer found he provided medical records do not indicate there is a medically necessary reason for the enrollee to get a second opinion out of area.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 referral have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea referral for a second opinion at an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forthe comprehensive oral evaluation and prophylaxis provided on October 29, 2019.You asked the Plan to pay forthe comprehensive oral evaluation and prophylaxis. You say that the drive to your previous provider's office was too risky to drive to, so you found a new dentist nearby. You also say that you would like these services approved because you only had the services performed one other time in 2019.The Plan denied your request. The Plan says that you exceeded the plan limits for these services.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide any documentation regarding when the enrollee last received a comprehensive oral evaluation and prophylaxis for this case. We asked for this documentation, but it was not provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case. Therefore, the plan has not substantiated their denial of payment in this case.Therefore, we decided that the Plan has to pay forthe comprehensive oral evaluation and prophylaxis provided on October 29, 2019.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 forphysician services provided on December 5, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was 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 involvingemergencies, 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 notpre-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 forphysician services provided on December 5, 2019 by an out of network(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe core build-up.You asked the Plan to pre-approvethe core build-up. You say that without the requested treatments an infection can occur. You say that the treatment should be approved.The Plan denied your request. The Plan says this 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 pre-approvethe core build-up.
Appeal type: Imaging
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 September 25, 2019.You asked the Plan to pay forthe 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 servicesat 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 theenrollee by an out-of-network provider on September 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided November 20, 2019.You asked the Plan to pay forthe dental services. You say that you had asked the dental office to make sure that everything was covered. They did two x-rays on that same day and had you known it was cosmetic you would not have did the services.The Plan denied your request. The Plan says this services is not listed as 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 for2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided November 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe CT scan provided on January 4, 2020.You asked the Plan to reduce the copayment forthe CT scan. You say that you were told your copayment would be $90. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 thePlan clearly says that you must pay a $225 copayment for each in-network Medicare-covered advanced imaging service (not including x-rays). You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to reduce the copayment forCT scan provided on January 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran eye exam (92012) provided on September 25, 2019.You asked the Plan to pay forthe eye exam. You say that you would like reconsideration because you believe this was a special need that shouldhave been included as part of the eye examination.The Plan denied your request. The Plan says your benefit covers one eye exam per year and you received an eye exam on January 22, 2019.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. The Plan covers one eye exam per year and the records indicate you received this service in January 2019.Therefore, we decided that the Plan does not have to pay foran eye exam (92012) provided on September 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe x-ray provided on December 11, 2019.You asked the Plan to waive the copayment forthe x-ray. You say that that according to your insurance you are not supposed to pay a $35 copayment for the x-ray. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 each outpatient x-ray, diagnostic procedure and test. You have been asked to pay a $35 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows you received a chest x-ray.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 x-ray provided on December 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) care.You asked the Plan to pre-approvecontinued SNF care. You say that the services are necessary.The Plan denied your request. The Plan says you have reached the 100-day benefit limit. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefitperiod begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from October 21, 2019 to April 16, 2020. The Plan has covered 100 days of SNF care.Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit periodwhen you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora chiropractic office visit (99212) provided on October 9, 2019.You asked the Plan to pay fora chiropractic office visit. You say that this was medically necessary for your neck and spine problems.The Plan denied your request. The Plan says this is not covered by Medicare or the Plan.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 service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay fora chiropractic office visit (99212) provided on October 9, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient mental health care visit provided on December 13, 2019.You asked the Plan to waive the copayment forthe outpatient mental health care visit. You say that there has been a lack of communication on the Plan's part for this claim. The Plan denied your request. The Plan says the claim was denied in error and reprocessed on December 31, 2019. There is a $10 copayment for a mental health care visitThe 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 $10 copayment for outpatient mental health care at an in-network specialist's office. You have been asked to pay a $10 copayment for the outpatient mental health care visit. The outpatient mental health care visit falls within the "Outpatient mental health care" 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 outpatient mental health care visit provided on December 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora skin biopsy provided on November 20, 2019.You asked the Plan to waive the copayment fora skin biopsy. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay the allowed amount of $224.68, which is less than the $325 copayment for a skin biopsy. A skin biopsy 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 basedon your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora skin biopsy provided on November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on January 22, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that there was no office visit at the time of service. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 thatyou must pay a $50 copayment for each in-network specialist visit for Medicare-covered services. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen for a diagnostic evaluation.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 specialist office visit provided on January 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe medical eye exam provided on November 21, 2019.You asked the Plan to waive the deductible forthe medical eye exam. You say that you had a routine eye exam and were not told that a medical exam would result in fees. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 deductible that applies towards in-network medical eye exams. The medical eye exam you asked the Plan to waive the deductible for falls within the "Vision care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible that applies towards in-network medical eye exams. The record shows a diagnosis of age-related cataracts which makes the exam medical in nature.This cost sharing is a contractual obligation that had not been met at the time the medical eye exam was received on November 21, 2019. Therefore, we decided that the Plan does not have to waive the deductible forthe medical eye exam provided on November 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe CT scan provided on December 11, 2019.You asked the Plan to waive the deductible forthe CT scan. You say that the charges shouldn't apply the deductible. You say that you should only have to pay a $50 copayment.The Plan denied your request. The Plan says the deductible applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $1,250, which applies to all items and services except those specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Advanced imaging services are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls "Outpatient diagnostic tests and therapeutic services and supplies" within the benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,250 deductible is applies to advanced imaging services. This cost sharing is a contractual obligation that had not been met at the time the CT scan was received onDecember 11, 2019. Therefore, we decided that the Plan does not have to waive the deductible forthe CT scan provided on December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveelectronic connection between wheelchair controller and two or more power seating system motors (E2311) expandable controller (E2377) expandable controller harness (E2313).You asked the Plan to pre-approvethe wheelchair accessories. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested items.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 wheelchair accessories. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found on review of the medical record, the enrollee does not meet the coverage criteria in that she does not need a special device for steering (such as a head switch or air puffs for control) on the wheelchair. She is not on a ventilator. She has 3/5 strength in the upper extremities which is adequate enough to manage and control the power options using their own switches which are included in the approved power chair. These are necessary when there is a medical need to control power options through a Joystick. There is no documentation in the records to substantiate that she needs a Joystick. The requested items/services at issue in this case are not medically reasonable or necessary. The enrollee should be encouraged to use her upper extremities to get stronger rather than provide automatic controls.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 wheelchair accessories have not been met.Therefore, we decided that the Plan does not have to pre-approveelectronic connection between wheelchair controller and two or more power seating system motors (E2311) expandable controller (E2377) expandable controller harness (E2313).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care (99310) rendered by the out of network (OON) provider on August 1, 2019.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 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 forthe subsequent nursing facility care (99310) renderedby the out of network (OON) provider on August 1, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve20 office consultations and treatment with "the doctor". You asked the Plan to pre-approvethe outpatient mental health services. You say that the services are medically necessary.The Plan denied your request. The Plan says there are network providers who can provide the services requested.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve20 office consultations and treatment with "the doctor".