Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an inpatient hospital stay provided from September 9, 2019 to September 14, 2019.
You asked the Plan to waive the coinsurance for an inpatient hospital stay. You say that you disagree with the out-of-network 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 40% coinsurance for out-of-network inpatient hospital care. You had an inpatient hospital stay at an out-of-network provider from September 9, 2019 to September 14, 2019. Therefore, you are responsible to pay your share of the out-of-network charges. The allowed amount is $10,700.86 and 40% of that is $4,280.34. You have been asked to pay the total coinsurance amount of $4,280.34 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 coinsurance for an inpatient hospital stay provided from September 9, 2019 to September 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate for enrollee.You asked the Plan to pre-approve Methotrexate. The Plan denied your request. The Plan says the enrollee's plan does not cover outpatient prescription drugs.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 Methotrexate for enrollee.Benefits for Methotrexatemay 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on February 22, 2019.
You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says that they were unable to discover any evidence of an established relationship between the member and the ordering physician.
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 for the lumbar sacral orthosis provided to the enrollee on February 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 29, 2019.
You asked the Plan to waive the copayment for the office visit. You say that the nurse practitioner sent you to urgent care. You say that you don't want to pay when you weren't treated. The Plan denied your request. The Plan says the copayment 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 $15 copayment per primary care physician (PCP) visit. You have been asked to pay a $15 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were examined during the office visit. 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 office visit provided on September 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One (J7326).
You asked the Plan to pre-approve Gel-One. You say that the Gel-One is medically necessary. The Plan denied your request. The Plan says the member does not meet step-therapy exception criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Gel-One. Our reviewer says that the enrollee has not trialed viscosupplemental treatments such as Monovisc and Orthovisc. Our physician reviewer found the documentation does not outline contraindications or reasons these medications were not considered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One (J7326).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on
August 21, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
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 for a wrist-hand orthosis
(L3916) provided to the enrollee on August 21, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the belt strap sleeve garment provided on September 26, 2019.
You asked the Plan to pay for the belt strap sleeve garment provided by the in-network provider. You say that you were fitted with a knee brace and would appreciate payment for it. The Plan denied your request. The Plan says that the knee brace is not a covered benefit.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. Medicare follows these rules. You received the belt strap sleeve garment from the in-network provider. The file does not show that Medicare provided notice that the belt strap sleeve garment provided by the in-network provider would not be covered. Under Medicare rules, this means the belt strap sleeve garment provided by the in-network provider is considered approved by Medicare. Therefore, we decided that the Plan has to pay for the belt strap sleeve garment provided on September 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora limited oral evaluation (D0140), the complete series of periapical x-rays (D0210), the panoramic x-ray (D0330), the surgical extraction (D7210), the treatment of an oral abscess (D7510), gingival irrigation (D4921), and the full mouth debridement (D4355) provided on August 30, 2019.You asked the Plan to pay forthe gingival irrigation and full mouth debridement. You say that the dentist shows as in network on the Plan's website. You also say that a Plan representative helped you make an appointment with the dentist's office.The Plandenied your request. The Plan says the gingival irrigation and full mouth debridement 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 dental services you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay fora limited oral evaluation (D0140), the complete series of periapical x-rays (D0210), the panoramic x-ray (D0330), the surgical extraction (D7210), the treatment of an oral abscess (D7510), gingival irrigation (D4921), and the full mouth debridement (D4355) provided on August 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic services provided to the enrollee on June 13, 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 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 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 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 diagnostic services provided to the enrollee on June 13, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on June 21, 2019.You asked the Plan to waive the copayment for the colonoscopy. You say that you have always had a preventive colonoscopy because of your family history. You say that you have never been charged for a polyp removal.The Plan denied your request. The Plan says the copayment 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 $300 copayment for each Medicare-covered outpatient surgery or procedure at an in-network outpatient hospital facility or ambulatory surgical center.You have been asked to pay a $300 copayment for the colonoscopy. The colonoscopy 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 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 colonoscopy provided on June 21, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the porcelain crown, fused to high noble metal,
(D2750) provided on August 27, 2019.
You asked the Plan to reimburse you for the dental service. The Plan denied your request. The Plan says a
porcelain crown, fused to high noble metal, is not listed as a covered service.
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 porcelain, fused to high noble
metal, crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have
to reimburse you for the porcelain crown, fused to high noble metal, (D2750) provided on August 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation.
You asked the Plan to pre-approve routine transportation. You say that you need transportation to your appointments once a week. The Plan denied your request. The Plan says your plan does not include a benefit for routine transportation.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Neither Medicare nor your plan cover routine transportation. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Androgel for the enrollee.
You asked the Plan to pre-approve Androgel. You say that the enrollee has tried alternative medications, and they have not helped. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
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 Androgel for the enrollee.
Benefits for Androgel 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463), collection of venous blood by venipuncture (36415), a lipid panel (80061), a complete blood count (CBC) (85025), a comprehensive metabolic panel (80053), and an electrocardiogram (ECG) (93005) provided on September 27, 2019
You asked the Plan to pay for a hospital outpatient clinic visit, collection of venous blood by venipuncture, a lipid panel, a CBC, a comprehensive metabolic panel, and an ECG. You say that you are appealing the claim payment denial for services rendered to the member on date of service September 27, 2019. The documentation will show that the service provided was clinically appropriate and medically necessary. You are requesting an authorization and for the claim to be reprocessed for payment. The Plan denied your request. The Plan says the rendering provider is a non-participating provider. The attending provider is also a non-participating provider. The plan did not authorize any services done by non-participating providers. The services are not considered urgent/emergent in nature. There are multiple in-network providers within 30 miles of the member's residence that could have rendered the 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 a hospital outpatient clinic visit (G0463), collection of venous blood by venipuncture (36415), a lipid panel (80061), a complete blood count (CBC) (85025), a comprehensive metabolic panel (80053), and an electrocardiogram (ECG) (93005) provided on September 27, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Verio test strips.You asked the Plan to pre-approve OneTouch Verio test strips. You say that you were told that the OneTouch Verio test strips would be covered when you enrolled in the plan.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-preferred brands).We looked at the file and Medicare rules. There is no documentation of a medical issue that requires the use of the OneTouch brand device. Without this documentation, medical necessity for the non-preferred brand is not able to be established. Based on this information, we decided that Medicare rules for coverage of OneTouch Verio test strips have not been met.Therefore, we decided that the Plan does not have to pre-approveOneTouch Verio test strips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Losartan tablets.You asked the Plan to pre-approveself-administered drugs. You say that the enrollee has tried other medications that did not work.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 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-approveLosartan tablets.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on August 6, 20019 and billed under codes 99223, 1124F and G8427.
You asked the Plan to pay for services rendered to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says the claim was not appropriately billed due to the "S" code status. The Plan says that based on the ICD-10 Manual, a sequela (7th character "S") code cannot be listed as the primary, first listed or principal diagnosis on a claim because coding of a sequela requires reporting of the condition or nature of the sequela sequenced first, followed by the sequela (7th character "S") code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the claim submitted has errors with the primary code preventing payment. The Plan states a corrected claim is needed. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on August 6, 20019 and billed under codes 99223, 1124F and G8427.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay foran ankle-foot orthosis (L1971) and a wrist-hand orthosis (L3916) provided to the enrollee on June 19, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.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 foran ankle-foot orthosis (L1971) and a wrist-hand orthosis (L3916) provided to the enrollee on June 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on September 20, 2019.
You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 on September 20, 2019.