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

We decided that the Plan does not have to pay for lab work provided on October 10, 2019 to November 12, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you assumed the member was referred by a provider who participated with the Plan. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 lab work provided on October 10, 2019 to November 12, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmology medical examination and evaluation (92014) provided January 23, 2020.
You asked the Plan to waive the copayment for the vision services. You say that you did not pay a copay for this service last year or the year before and the doctor's office did not ask for the copay at the time of the appointment. You should not be responsible for this copay. The Plan denied your request. The Plan says the claim was processed correctly and the correct copay 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 $20 copayment for medical eye exams. for Vision care. You have been asked to pay $20 for the vision services. The vision services fall within the Vision 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 for ophthalmology medical examination and evaluation (92014) provided January 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services coded 80156, 80157, 80177, 80201, 80162, 80159, and 80173 provided on August 21, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.ThePlan denied your request. The Plan says the services rendered are not supported by the documentation.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 codes 80156, 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition form of medical records stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services coded 80156, 80157, 80177, 80201, 80162, 80159, and 80173 provided on August 21, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray coded 71045 provided on December 10, 2019.You asked the Plan to pay forthe x-ray. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed should not be reported separately.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code71045 forthe x-ray has a bundled relationship with code 32555and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forthe x-ray coded 71045 provided on December 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on January 31, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed must only be paid by the secondary payer if the services have been denied by your primary insurer.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 directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the laboratory services until the primary insurer has denied the claim for these services.Review of the file shows that while the primary insurer has made a payment, you are responsible for the cost share amount based on the primary insurer's plan benefit. The secondary insurer does not make a payment for your deducible and coinsurance amount of the primary insurer. Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on January 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric services provided from October 18, 2019 to November 13, 2019.
You asked the Plan to pay for the inpatient psychiatric services. 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 medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient psychiatric services. Our reviewer says that the documentation does not support that the services rendered are medically reasonable or necessary. Our physician reviewer found the enrollee did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety not requiring one-on-one supervision. The documentation does not support that it was medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question, as the enrollee did not have dangerousness to self or others but was compliant with the enrollee's treatment. The documentation does not support that the services
were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. Therefore, the enrollee did not meet criteria for the services rendered 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 inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric services provided from October 18, 2019 to November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services received on November 21, 2019.You asked the Plan to waive the copayment for the services. You say that you cannot pay the copayment, and the plan should reprocess the claim.The Plan denied your request. The Plan says you are responsible for the copayment 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 Medicare-covered eye exams. You have been asked to pay a $50 copayment for the services. The services fall within the Medicare-covered eye exams 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 vision services received on November 21, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetrigger point injections.You asked the Plan to pre-approvetrigger point injections (20552, 20553). You say that the enrollee has received relief from trigger point injections.The Plan denied your request. The Plan says trigger point injections are considered as palliative and not show to have a long term effect on the pain.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 trigger point injections (20552, 20553). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found repeated trigger point injections is not standard therapy. The request is not medically reasonable or 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 trigger point injections (20552, 20553) have not been met.Therefore, we decided that the Plan does not have to pre-approvetrigger point injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a bilateral carotid Doppler and echocardiogram provided on November 27, 2018.You asked the Plan to pay for the bilateral carotid Dopplerand echocardiogram. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a bilateral carotid Doppler and echocardiogram provided on November 27, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay more toward the cost of magnetic resonance imaging (MRI) services provided on October 18, 2019.You asked the Plan to pay more toward the cost of the MRI services. You say that you would like to be reimbursed the full amount you paid for the MRI services.The Plan denied your request. The Plan says they have paid the Medicare allowed amount for the MRI services in dispute.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that your share of costs for covered services provided out-of-network may be higher. Your contract with the Plan clearly says that the Plan won't pay any more than the amount that would have gotten paid if the services were provided under an Original Medicare Plan.The Plan reimbursed you $73.44 for the MRI in dispute. This was the total allowed amount. The provider who supplied these services is not a contracted provider with the Plan. The provider's charges beyond the total allowed amount are not the responsibility of the Plan to pay.Therefore, we decided that the Plan does not have to pay more toward the cost of magnetic resonance imaging (MRI) services provided on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean office visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approvean office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a 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 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 an office visit to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided November 25, 2019.You asked the Plan to pay forthe dental services. You say that when you visited the web site, the dentist was listed as a network provider.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider has opted out of the Medicare program. The file shows that  entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay forthe dental services provided November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approverapid desensitization services.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the diagnosis is not supported.The Plan must follow Medicare rules. Medicare rules say that rapid desensitization is covered when specific criteria are met.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have allergic rhinitis. The records do not show that you have a condition for which rapid desensitization is covered by Medicare. The criteria for coverage are not met and the services are therefore not reasonable or medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approverapid desensitization services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have topre-approveGelsyn-3 injection services.You asked the Plan to pre-approvethe Gelsyn-3 injection services. You say that the enrollee was denied for Synvisc and their facility is only able to order Gelsyn-3 or Synvisc. You say that the enrollee has been getting Kenalog injections without any relief. You say that the enrollee is unable to do physical therapy, is not a surgical candidate, and has end stage osteoarthritis with extreme uncontrolledThe Plan denied your request. The Plan says Gelsyn is not a preferred drug. The Plan says that Euflexxa and Gel-one injections are preferred. The Plan says that in order to approve Gel-One or Euflexxa, they will need x-rays for both knees and documentation showing whether the enrollee has tried and failed physical therapy.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 the Gelsyn-3 injection services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the Gelsyn-3 is being requested for treatment of osteoarthritis in bilateral knees. The enrollee has not trials viscosupplemental treatments such as Euflexxa and Gel-One. The plan requires these drugs betrialed. The documentation provided 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 the Gelsyn-3 injection services have not been met.Therefore, we decided that the Plan does not have to pre-approveGelsyn-3 injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 4, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been 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 thePlan. The Plan did not pre-approve the physician's services.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 physician's services provided on November 4, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay forthe Mammaprint test provided to the enrollee on September 6, 2019.You asked the Plan to pay forthe test. You say that prior authorization is not required, particularly in light of the fact that Mammaprint is covered by fee-for-service Medicare.The Plan denied your request. The Plan says that these services were not authorized.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. The Plan follows these rules.Theenrollee was referred for the test by a contract provider. The file does not show that the plan provided notice that the test would not be covered. Under Medicare rules, this means the testis considered approved by the Plan.Therefore, we decided that the Plan has to pay forthe Mammaprint test provided to the enrollee on September 6, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forintraoral periapical radiographic imaging provided on December 3, 2019.You asked the Plan to pay forthe intraoral periapical radiographic imaging. You say that you feel cheated. You say that the dentist was full of lies and overcharged you.The Plan denied your request. The Plan says your Evidence of Coverage does not provide a benefit for periapical x-rays.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 forintraoral periapical radiographic imaging provided on December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four gingival irrigations and periodontal maintenance provided on December 17, 2019.You asked the Plan to pay for the gingival irrigations and periodontal maintenance. You say that you understand that you are entitled to two cleanings per year, and you only had two cleanings, so the denial because of frequency does not make sense. You also say that cleanings are very important for your health, and if you are charged the full amount every time you go in, cleanings may not be possible for you in the future.The Plan denied your request. The Plan says gingival irrigation is not a covered benefit under your dental plan. The Plan also says that the periodontal maintenance service exceeds the frequency limitation in your benefit plan.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, gingival irrigation is not among those covered under this benefit. The contract also clearly states that periodontal maintenance is limited to two procedures per calendar year. The record shows that you received periodontal maintenance services on January 29, 2019 and June 4, 2019and your periodontal maintenance benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the four gingival irrigations and periodontal maintenance provided on December 17, 2019.