Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy (45378) provided on October 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an OON colonoscopy. You say that the facility should have obtained authorization for these services. The Plan denied your request. The Plan says these 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 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 colonoscopy (45378) provided on October 24, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office service. You say that the provider said that you would be covered. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and you could have been treated by an in-network 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 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 medical services provided on October 10, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a specialist office visit provided on July 30, 2019.
You asked the Plan to waive the coinsurance for a specialist office visit. You say that you are on a fixed income and cannot afford this coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been 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 20% coinsurance for physician/practitioner services/specialist. You have been asked to pay a 20% coinsurance of the allowed amount for a specialist office visit. The total allowed amount is $130.09. The total amount you are being asked to pay is $26.02 ($130.09 x 20% = $26.02). A specialist office visit falls within the physician/practitioner services/specialist 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 a specialist office visit provided on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99309) provided on November 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for nursing facility care. You say that these services were medically necessary. The Plan denied your request. The Plan says these 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 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 nursing facility care (99309) provided on November 5, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient hospital services rendered on September 23, 2019.
You asked the Plan to waive the coinsurance for these services. You say that the services should be covered as in-network. The Plan denied your request. The Plan says the coinsurance 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 30% coinsurance for each out-of-network outpatient hospital and observation service.
Review of the file shows that you received outpatient hospital services on September 23, 2019. You have been asked to pay a 30% coinsurance for these services. These services fall within the each out-of-network outpatient hospital and observation service 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 the outpatient hospital services rendered on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network gynecologist.
You asked the Plan to pre-approve the referral. You say that there is no qualified gynecologist nearby for a surgery that you need. The Plan denied your request. The Plan says there are in-network
providers available to treat you.
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-approve
a referral to an out-of-network gynecologist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse additionally for the immunizations received by an out-of-network provider on October 11, 2019.
You asked the Plan to reimburse additionally for the immunizations received by an out-of-network provider. You say that you feel you should be reimbursed the full amount you paid. The Plan denied your request. The Plan says you received a vaccine on the date of service at issue in this appeal. The Plan says you received your vaccine provided by an out-of-network provider. The Plan says the correct copayment has applied per your contract with the Plan.
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 $30 copayment for the pneumonina, influenza, and Hepatitus B vaccine when provided by an out-of-network provider. We looked at the file, the Plan's contract and Medicare rules. The file shows you received your vaccine provided by an out-of-network provider on October 11, 2019. You have been asked to pay a $30 copayment for the immunizations received by an out-of-network provider. The immunizations received by an out-of-network provider falls within the Immunizations 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 reimburse additionally for the immunizations received by an out-of-network provider on October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network ophthalmologist.
You asked the Plan to pre-approve these services. You say that you had eye surgery with this provider in 2018.
The Plan denied your request. The Plan says the services are available from 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 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-approve
a referral to an out-of-network ophthalmologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4921 x 4), drugs or medicaments
(D9630), observation (D9430 x 2), localized delivery of antimicrobial agents (D4381), guided tissue
regeneration (D3432), and a bone replacement graft (D7953).
You asked the Plan to pre-approve the dental services. You say that this treatment plan was recommended by
your dentist. You say that you contacted the dentist for an alternative treatment plan, but they are closed. The
Plan denied your request. The Plan says the dental services that you requested are not listed as covered
services.
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 dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
gingival irrigation (D4921 x 4), drugs or medicaments (D9630), observation (D9430 x 2), localized delivery of
antimicrobial agents (D4381), guided tissue regeneration (D3432), and a bone replacement graft (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception for an office visit (99214) with
an out-of-network provider.
You asked the Plan to pre-approve the in-network exception. You say that you would like reconsideration
because you have been seeing this provider for 13 years. The Plan denied your request. The Plan says you have
out-of-network benefits and there are multiple in-network specialist options.
The Plan must follow Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in
clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance).
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the in-network exception have not been met. Specifically, the record indicates that you have out-of-
network benefits and there are other options for in-network care available. Therefore, we decided that the
Plan does not have to pre-approve an in-network exception for an office visit (99214) with an out-of-network
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for A Lumbar-Sacral Orthosis (L0650) provided December 10, 2019.
You asked the Plan to pay for the orthosis. You say that the items were medically necessary. The Plan denied your request. The Plan says the records provided do not support the medical necessity of the orthosis.
The Plan must follow Medicare rules. Medicare rules say that the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered. We looked at the file and Medicare rules. The records include a delivery ticket and order form, but the medical records provided do not show details of any discussion with the provider surrounding the need of the DME items. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for A Lumbar-Sacral Orthosis (L0650) provided December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 physician services provided on September 10, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process
stabilization/distraction device (22869 and 22870).
You asked the Plan to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction
device. You say that this is medically necessary. The Plan denied your request. The Plan says this is
experimental.
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 insertion of
interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services
are not considered medically reasonable and necessary in this case. Our physician reviewer found this device
remains experimental. More research is needed before it can be considered medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the insertion of interlaminar/interspinous process stabilization/distraction device
have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of
interlaminar/interspinous process stabilization/distraction device (22869 and 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a spinal orthosis (L0457) provided on December 13, 2019.
You asked the Plan to pay for a spinal orthosis. You say that the spinal orthosis provided was medically
necessary. The Plan denied your request. The Plan says the services do not meet criteria.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for a spinal orthosis. Our reviewer says that the
services do not meet criteria. Our physician reviewer found the enrollee's chief complaint was chronic lower
back pain. The available documentation in the case file does not support that the requested lumbar-sacral
orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria
established by the LCD. An appropriate history and a physical examination of the back would reasonably be
required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does
not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this
case, as there is no documentation of a credible physical examination of the back.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a spinal orthosis have not been met. Therefore, we decided that the Plan does
not have to pay for a spinal orthosis (L0457) provided on December 13, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home nursing care visits.
You asked the Plan to pre-approve home nursing care visits. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home nursing care visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not show a decline in functional or medical status or care plan to warrant continued skilled nursing visits. Skilled nursing visits are not required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home nursing care visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home nursing care visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abdominal binder (A4467).
You asked the Plan to pre-approve an abdominal binder. You say that you were advised an exception would be made and these items would be covered. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that elastic or other fabric support garments (A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANYTYPE)) with or without stays or panels do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an abdominal binder have not been met. Therefore, we decided that the Plan does not have to pre-approve an abdominal binder (A4467).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood smear interpretation (85060) provided on November 18, 2019.
You asked the Plan to pay for the blood smear interpretation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the only payment made for the profession component of CPT code 85060 is for hospital inpatients.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 85060 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 85060 has a PC/TC indicator of 8. This indicator identifies the professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. In this case, CPT code 85060 has been billed with Place of Service Code 22 for outpatient hospital. Based on this information, we decided that Medicare rules for coverage of the blood smear interpretation have not been met. Therefore, we decided that the Plan does not have to pay for a blood smear interpretation (85060) provided on November 18, 2019.
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 December 4, 2019.
You asked the Plan to pay for the 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 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 December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 3, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you feel that you should not owe a copayment just to have results read. 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 $20 copayment for specialist visits. You have been asked to pay a $20 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 enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on January 3, 2020.