Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forperiodic oral evaluation (D0120) provided on May 8, 2019 by an out-of-network provider.You asked the Plan to pay forthe dental services. You say that you were not aware that you had to use an in-network provider.The Plan denied your request. The Plan says you do not have out-of-network benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, thePlan's coverage rules apply in this case.The provider is not in-network and your EOC clearly states, to be covered in-network, you need to use a provider  that is contracted with our dental vendor to provide  supplemental dental services. Care rendered by a provider that is not part of our supplemental dental  network is not covered.Therefore, we decided that the Plan does not have to pay forperiodic oral evaluation (D0120) provided on May 8, 2019 by an out-of-network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe wound care provided from September 5, 2019 to September 19, 2019.You asked the Plan to reduce the copayment forthe wound care. You say that you should only be paying a $45 copayment. You say you were not at a hospital.  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 $200 copayment for each Medicare-covered outpatient hospital facility visit. You have been asked to pay a $173 copayment, which is less than the standard copayment, for the wound care. The wound care falls within the "Outpatient Surgery, including services provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows you were billed by an outpatient hospital.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment forthe wound care provided from September 5, 2019 to September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 12, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the out-of-network services. You say that the procedure code does not require authorization. The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits.
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 on September 12, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forabdominal paracentesis (49083) provided on May 29, 2019.You asked the Plan to pay for the abdominal paracentesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the service requested does not meet the requirements for payment by the Medicare Advantage plan.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for abdominal paracentesis (49083) provided on May 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer-crown, teeth 17, 21 (D6740) and Pontic teeth 19, 20 (D6210).
You asked the Plan to pre-approve the dental services. You say that the enrollee is unable to wear dentures or partials because they irritate her gums and is requesting coverage for the bridge in order to have the space filled. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retainer-crown, teeth 17, 21 (D6740) and Pontic teeth 19, 20 (D6210).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided to the enrollee on October 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service would be included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided to the enrollee on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay foroffice visit services provided to the enrollee on September 26, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe provider is not contracted with 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 rendering 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 Plandoes not haveto pay foroffice visit services provided to the enrollee on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 18, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe out-of-network services. You say that the documentation supports medical necessity.The Plan denied your request. The Plan says an authorization to cover the services is required.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 out-of-network services. Therefore, we decided that the Plan does not have to pay forthe medical services provided on September 18, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided by on October 11, 2019.You asked the Plan to waive the copayment forlaboratory services. You say that the laboratory services should be included in the annual physical.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 $10 copayment for laboratory services. You received laboratory services on October 11, 2019. Laboratory services are not included in the annual wellness exam. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forlaboratory services provided on October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe atezolizumab injection and chemotherapy administration provided on October 4, 2019.You asked the Plan to waive the coinsurance forthe atezolizumab injection and chemotherapy administration. You say that the out-of-pocket maximum was reached. You say that the cost should be covered.The Plan denied your request. The Plan says the coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare Part B chemotherapy drugs, associated administration services and all other Medicare Part B drugs from an in-network provider.The enrollee has been asked to pay $404.09, which is less than the standard 20% coinsurancefor the atezolizumab injection and chemotherapy administrationbecause you met your maximum out-of-pocket. ServiceAllowed AmountStandard CoinsuranceMember LiabilityChemotherapy Administration$134.8420%$26.97Atezolizumab Injection$9,241.2020%$377.12-Met Max OOPTOTAL:$404.09
The atezolizumab injection and chemotherapy administration falls within the "Medicare Part B prescription drugs" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe atezolizumab injection and chemotherapy administration provided on October 4,2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe physician visits provided on October 17, 2019 and October 18, 2019.You asked the Plan to waive the copayment forthe physician visits. You say that you were an inpatient. You say that you should not have to pay for a specialist during your hospital stay.The Plan denied your request. The Plan says the copayments 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 $40 copayment for each in-network specialist visit for Medicare-covered benefits. Covered services include medically-necessary medical care or surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location.You have been asked to pay a total of $78.08 for the physician visits. Date of ServiceServiceAllowed AmountStandard CopaymentMember LiabilityOctober 17, 2019Physician Visit$70.15$40$40October 18, 2019Physician Visit$38.08$40$38.08TOTAL:$78.08. The physician visitsfall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were admitted to outpatient observation. This means that you have been asked to pay the correctamount 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 physician visits provided on October 17, 2019 and October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids providedon September 6, 2019.You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says The hearing benefit is not covered if the services are not ordered through the designated vendor.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's designated vendor.We looked at the fileand the Plan's rules. The provider at issue in this appeal is not a Plan vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on September 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePennsaid lotion for the enrollee.You asked the Plan to pre-approvethis drug. You say that this is medically necessary.The Plan denied your request. The Plan says that this drug is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administereddrugs 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-approvePennsaid lotion for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEpogen.You asked the Plan to pre-approvethe Epogen. You say that the requested drug is medically necessary.The Plan denied your request. The Plan says the information submitted does not meet the plans medical necessity guidelines for coverage.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 topre-approve the Epogen. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drug Retacrit before they will approve the requested drug. Per the reviewed documentation the enrollee has not tried and failed the required drug. The Plan's required drug(s) would not likely be less effective and/or likely have adverse effects for the enrollee. Retacrit (epoetin alfa-epbx), from Hospira, and Procrit (epoetin alfa), from Janssen, are both erythropoiesis-stimulating agents (ESA) used to help improve red blood cell production. Retacrit is also a biosimilar to Epogen.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of the Epogen have not been met.Therefore, we decided that the Plan does not have to pre-approveEpogen.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 23, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient hospital services. You say that these services were deemed as medically necessary.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring physician is also out-of-network with 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 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 thePlan does not have to pay forthe medical services provided on April 23, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient emergency room services provided to the enrollee
on May 14, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says these codes are for inpatient procedures only.
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 33967 and C9606 is not supported in the medical record. Specifically, the claim was
billed as outpatient services, but these codes are for inpatient procedures only. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan
does not have to pay for outpatient emergency room services provided to the enrollee on May 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora resin based composite, 2 surfaces, for an anterior tooth provided on September 23, 2019.You asked the Plan to pay fora resin based composite, 2 surfaces, for an anterior tooth. You say that you had cancer and chemotherapy treatment. You also say that it destroyed your teeth.The Plan denied your request. The Plan says 2 fillings are covered per calendar year are covered. The Plan also says that the frequency limit has been exceeded.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 and fillings are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for 2 fillings that you received on the same date of service.Therefore, we decided that the Plan does not have to pay fora resin based composite, 2 surfaces, for an anterior tooth provided on September 23, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the physical therapy visits provided from January 30, 2019 to February 14, 2019.
You asked the Plan to reduce the copayments for the physical therapy visits. You say that you paid the in-network $10 copayment for the three visits and have now been billed for more money. You say you have been billed in error. 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 $65 copayment for physical therapy at an out-of-network specialist's office. You have been asked to pay a $65 copayment for each of the physical therapy visits. The physical therapy visits fall within the "Outpatient rehabilitation services" benefit category. The record shows the provider is out-of-network.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayments for the physical therapy visits provided from January 30, 2019 to February 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe drug testing provided on January 3, 2019.You asked the Planto pay forthe drug testing. You say that this was ordered by the treating provider and was medically necessary.The Plandenied your request. The Plansaysthe order is not signed until after the date of service and is not valid.The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating provider. The order need not be signed but there must be evidence in the record that the provider intended to order this testing.The order form was not signed at the timeof testing. There is no corresponding visit note or any other documentation around the date of service that supports that there was intent for this testing to be performed.Therefore, we decided that the Plandoes not haveto pay forthe drug testing provided on January 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on October 9, 2019.
You asked the Plan to reimburse you for the dental service. You say that periodontal maintenance is considered preventive dental. The Plan denied your request. The Plan says periodontal maintenance is not a preventive dental service. The Plan also says that it 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, periodontal maintenance is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on October 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe automatic blood pressure monitor provided October 30, 2019.You asked the Plan to pay forthe automatic blood pressure monitor. You say that the records should support the necessity of the service is dispute.The Plan denied your request. The Plan says this service is not covered.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the automatic blood pressure monitor have not been met.Therefore, we decided that the Plan does not have to pay forthe automatic blood pressure monitor provided October 30, 2019.