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

We decided that the Plan does not have to pay for an office visit provided on March 15, 2019 by out of network provider
You asked the Plan to pay for an office visit. You say that you would like the claim approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the primary care physician did not refer these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on March 15, 2019 by out of network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network provider. 
 
You asked the Plan to pre-approve the referral for out-of-network services. You say that the referral is needed and you would like the services to be local. The Plan denied your request. The Plan says this provider is not in your network and there is no medical reason as to why you cannot receive these services in-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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. 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-approve the medical services to be provided by an out of network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on April 2,
2019 to September 12, 2019
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically
necessary and should be covered. The Plan denied your request. The Plan says there are in-network providers
that can render the services at issue. The services were not emergent or preauthorized. There was no referral to
the out-of-network provider by 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the 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 outpatient mental health services provided on April 2, 2019 to September 12,
2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee out of network on
June 12, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for this service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee out of
network on June 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an annual wellness visit (G0438) provided on December 11, 2018.
You asked the Plan to waive the coinsurance for the annual wellness visit. You say that you would like reconsideration as you paid the copay at the time of the office visits and were not informed any more money was owed. The Plan denied your request. The Plan says this service was not an annual wellness visits and should therefore be paid with out-of-network benefits applied.
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% coinsurance for out-of-network for Annual Wellness Visit. You have been asked to pay a 50% coinsurance for out-of-network for the annual wellness visit. the annual wellness visit falls within the Annual Wellness Visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an annual wellness visit (G0438) provided on December 11, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on March 27, 2019.You asked the Plan to pay forthe orthosis. You say that the durable medical equipment is medically necessary.The Plandenied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.The Plan must follow Medicare rules. Medicare rules say 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 forshoulder elbow wrist hand orthosis (L3960) provided to the enrollee on March 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on July 25, 2019 by out of network provider.
You asked the Plan to pay for an office visit. You say you did not know this patient had this insurance until she came in and brought the ID card. You could not have known that you needed to obtain authorization for out of network benefits. The Plan denied your request. The Plan says the doctor is not an in-network provider as he does not work with the health plan and the member self-referred for services. The primary care provider did not refer the member. The health plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessary for an out-of-network provider, such as an urgent or emergency situation, was documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on July 25, 2019 by out of network provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services beyond February 8, 2020.
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee's coverage has ended but she still requires care and needs more time to determine where she can be placed after discharge. The Plan denied your request. The Plan says that the enrollee no longer needs skilled services on a daily basis.
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 provided only ten pages of records from the SNF. From these records, it is not possible to even determine when the enrollee was admitted to the facility nor any of the therapy services provided during the stay. It is not clearly noted anywhere in the file when the enrollee was admitted or any information about her condition/functional status when she arrived. The records consisted of short social work and nursing notes and nothing more. We find that the submitted records are insufficient to make a valid determination on whether daily skilled services continue to be required. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services beyond February 8, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forself-administered drugs provided September 17, 2019.You asked the Plan to pay forthe self-administered drugs. You say that the drugs should be covered.The Plan denied your request. The Plan says the drugs provided were self-administered and not covered under the medical benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forself-administered drugs provided September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for crutch substitute, lower leg platform, with or without wheels, each (CPT Code E0118) purchased from a non-contracted provider on July 2, 2019.
You asked the Plan to pay for the DME. You say that you need a knee scooter because of the compound fracture and an open wound on your right ankle that is larger than the size of a quarter. You state that you could not be put in a cast or wear a boot. The Plan denied your request. The Plan says the DME is not medically necessary.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. There is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for this product. Therefore, we decided that the Plan does not have to pay for crutch substitute, lower leg platform, with or without wheels, each (CPT Code E0118) purchased from a non-contracted provider on July 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycontin tablets. 
 
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee is stable and has improved with this medication since 2018. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. The Plan also says that the enrollee's Medicare Part D prescription drug benefits may be administered by Express Scripts. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycontin tablets.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from July 22, 2019
through July 30, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were admitted to the hospital for the same medical condition and it should be a continuation of the treatment from when you
were admitted at the medical center. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2019 EOC 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).
Review of the file shows that you were admitted on July 22, 2019 and discharged on July 30, 2019. You were
asked to pay a $295 copayment per day from July 22, 2019 through July 26, 2019, days 1-5 of your inpatient
hospital care. There were no copayment charges from July 27, 2019, day 6 of your inpatient hospital care until
your day of discharge July 30, 2019. Per your contract there is a $295 copayment per day required for days 1-5.
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 inpatient hospital care from July 22, 2019 through July 30,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on September 3, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that the visit was supposed to be a follow-up after your procedure on August 28, 2019. You say this was supposed to be covered in full. 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 $50 copayment for each in-network specialist visit for Medicare-covered services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $50 copayment for the specialist office visit.
You have been asked to pay a $47.18 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.
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 the specialist office visit provided on September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on August 31, 2018 by an out of network provider.
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on August 31, 2018 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an oral evaluation (D0120) and prophylaxis (D1110)
provided on September 19, 2019.
You asked the Plan to pay for the dental services. You say that you were told by a Plan representative that the
dental services are covered. The Plan denied your request. The Plan says these services were provided after the
Plan was terminated.
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 Medicare. Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0120) and
prophylaxis (D1110) provided on September 19, 2019.
Your complaint stating that you were told these services would be covered by the Plan is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve peripherally implanted nerve stimulation (64555).You asked the Plan to pre-approve peripherally implanted nerve stimulation. You say that the services are medically necessary.The Plan denied your request. The Plan says that medical necessity hasnot been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 peripherally implanted nerve stimulation. Our reviewer saysthat the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found there is reasonable published literature to support some benefit and functional improvement of percutaneous peripheral nerve stimulation in the form of randomized controlled trials (RCTs) and other prospective studies to show safety, efficacy and durability of moderate length. The enrollee has failed all conservative treatments. The treatment is not investigational and is FDA approved for treatment of chronic back pain. The request is not for the convenience of the enrollee or provider and is determined within the medical community to offer greater benefit than the conservative options which the enrollee has not responded to.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of peripherally implanted nerve stimulation have been met.Therefore, we decided that the Plan has to pre-approve peripherally implanted nerve stimulation (64555)
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided on January 23, 2019.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the summary of benefits submitted with the appeal was not an accurate explanation of benefits for the service date in question.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an EOB from the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the chest x-ray until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided on January 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary due
to a hypoglycemia diabetic situation. An ambulance was called because you were unresponsive. You say that
after treatment you began to stabilize and declined transport to the hospital. You believe that the additional
emergency room visit would have incurred a large medical bill and you say that you are on a limited budget.
The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on June 18, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.