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

We decided that the Plan does not have to pay for drug testing (G0481, 80307) provided on September 4, 2019 by the out of network provider.
You asked the Plan to pay for drug testing. You say that you are in the process of participating with all lines of business with the Plan. You did not realize this patient's plan required an authorization. The Plan denied your request. The Plan says services from non-participating providers are not covered under the Plan unless they are authorized before the services are provided.
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 drug testing (G0481, 80307) provided on September 4, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the surgical
extraction (D7210) provided on July 8, 2019 by an out of network provider.
You asked the Plan to pay for the dental services. You say that prior to your appointment for these services,
you called the provider's office to make sure that they are in network. You say that the provider's office advised
that they were in network. The Plan denied your request. The Plan says the provider in this case is not a
network provider. The Plan also says care rendered by a provider that is not part of our supplemental dental
network is not covered.
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
covered when they are performed out of network. Additionally, the record shows that you did not contact the
plan to verify the provider's network status before receiving the services. Therefore, we decided that the Plan
does not have to pay for the limited oral evaluation (D0140) and the surgical extraction (D7210) provided on
July 8, 2019 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory tests. You say that you are in disagreement with the Plan's denial. 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 ordering 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 the Plan does not have to pay for the medical services provided on December 10, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve noise cancelling ear plugs.
You asked the Plan to pre-approve the noise cancelling ear plugs. You say that your conditions have worsened. You say that without these ear plugs, this is negatively impacting your daily life. You say that the plan covered these ear plugs for you before, but they never worked. You say that you were told that over the years the ear plugs will wear out, and more would be covered. The Plan denied your request. The Plan says the requested device is non-medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve noise cancelling ear plugs.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on December
13, 2019.
You asked the Plan to waive the copayment for the laboratory work. You say that the laboratory work was in
preparation for your annual physical. You say you should not be responsible for the copayment. 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 $20
copayment per visit for laboratory tests, non-radiological tests, diagnostic tests, flat film x-rays, and
ultrasounds.
You have been asked to pay a $20 copayment for the laboratory work. The laboratory work falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the
laboratory work is a separate service.
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 laboratory work provided on December 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 1, 2019 by out of
network provider.
You asked the Plan to pay for an x-ray. You say that your portable x-ray services does not require a preauthorization
as they are not scheduled exams. 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 the medical services provided on July 1, 2019 by
out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for spinal surgery provided on March 15, 2019.
You asked the Plan to pay for surgical services. You say that even though this provider is out-of-network, the Plan reimburses out-of-network services provided to you. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider has opted out of Medicare coverage and is excluded from payment.
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. Therefore, we decided that the Plan does not have to pay for spinal surgery provided on March 15, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213), and psychotherapy (90834) provided
from July 10, 2019 through July 25, 2019 by the out of network provider.
You asked the Plan to pay for an office visit and psychotherapy. You say that the client was not advised that a
referral was needed when she signed up for this policy. The Plan denied your request. The Plan says services
from non-participating providers are not covered under the plan unless they are authorized by the Plan before the
services are provided.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an office visit (99213), and psychotherapy (90834)
provided from July 10, 2019 through July 25, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CPAP device (CPT Code E0601) and humidifier, heated, used with positive airway pressure device (CPT Code E0562).
You asked the Plan to pre-approve the DME. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The medical records submitted does not show your symptoms. The medical records do not show that you meet criteria A-C above. Therefore, you do not meet the medical criteria requirements for CPAP machine. Therefore, we decided that the Plan does not have to pre-approve CPAP device (CPT Code E0601) and humidifier, heated, used with positive airway pressure device (CPT Code E0562).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care provided on September 10, 2019.
You asked the Plan to waive the copayment for vision care. You say that the eye measurement is a requirement for the cataract surgery. You say that you should not have a separate copayment for this. The Plan denied your request. The Plan says the correct copayment 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 $30 copayment for vision care/medical eye exam. You have been asked to pay a $30 copayment for vision care. The correct copayment has been applied to the services that were provided. Vision care falls within the vision care/medical eye exam 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 care provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203), and an x-ray (73630) provided on
October 30, 2019 by out of network provider.
You asked the Plan to pay for an office visit and an x-ray. You say that when you called the office, they told
you they took the Plan. You didn't know you wouldn't be covered for the services and would like them
to be covered since you were told they would. The Plan denied your request. The Plan says while you are a
member of the plan you must use network providers to get your medical care and services. The only exceptions
are emergencies, urgently needed services when the Plan's network is not available (generally, when you are
out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an office visit (99203), and an x-ray (73630)
provided on October 30, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The
Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the services are not medically necessary. Our physician reviewer found the enrollee is currently
undergoing treatment at an acute care hospital (ACH) for a psoas hematoma, apparently related to
anticoagulation following recent posterior strokes. The enrollee is not intubated/ventilated. As LTACHs and
ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the
LTACH. The enrollee can remain at the current ACH until such time no acute services are required.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from August 6, 2018 through August 13, 2018.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $195 copayment per day for days 1-10 for inpatient coverage. The enrollee had an inpatient hospital stay provided from August 6, 2018 through August 13, 2018. Therefore, the enrollee is responsible to pay a $195 copayment for days 1-7 (August 6, 2018 through August 12, 2018). $195 (copayment) x 7 (inpatient days) = $1,365.00.The enrollee has been asked to pay the total copayment amount of $1,365.00 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient coverage 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 copayment for an inpatient hospital stay provided from August 6, 2018 through August 13, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1851) and a suspension sleeve (L2397)
provided on September 17, 2019.
You asked the Plan to pay for a knee orthosis and suspension sleeve. You say that this was medically
necessary. The Plan denied your request. The Plan says there is no 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 a knee orthosis (L1851) and
a suspension sleeve (L2397) provided on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213), and an osteopathic manipulative
treatment (an OMT) (98929) provided on July 3, 2019 by out of network provider.
You asked the Plan to pay for an office visit and an OMT. You say that you disagree with the denial and state
that the Dr. is Board Certified in Neuromuscular Skeleton Medicine. You say that the denied services were
for CPT code 98929 treatments and the services should be covered. The Plan denied your request. The Plan
says according to the enrollee's EOC if you want to use a specialist that is not in the Gateway Health Medicare
Assured network, your physician must get prior authorization. The Plan says the enrollee received services
from an out of network provider without a prior authorization. The Plan further says that records show there are
3 participating providers in the enrollee's area who provide Osteopathic Manipulative Treatment Procedures.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an office visit (99213), and an osteopathic
manipulative treatment (an OMT) (98929) provided on July 3, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound debridement provided on October 22, 2019.
You asked the Plan to waive the copayment for the wound debridement. You say that that the staff looked at the sore on your foot and bandaged it. You say no surgery was done. 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 $300 copayment for each Medicare-covered outpatient hospital facility visit. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $300 copayment for wound debridement.
You have been asked to pay a $174.31 copayment for the wound debridement. The wound debridement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows wound debridement services are considered a surgical procedure.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the wound debridement provided on October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the remaining balance for the crown (D2740) provided on July 2, 2019 by an out of network dentist.
You asked the Plan to pay the remaining balance for the dental service. You say that you had bridge work done on July 2, 2019. You say that the total bill was $1179. You say that the Plan allowed $1062.67 and paid 75% or $747.20. You also say that the Plan should cover what your primary coverage does not. The Plan denied your request. The Plan says your primary dental insurance paid the full allowable amount of 75%. The Plan also says that the provider in this case is not a network provider.
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 crowns are a covered service, the full dental benefit has already been paid. Crowns received from an out of network dentist are covered at 75%. The record shows that your primary dental plan already paid 75% of the allowed amount. Therefore, we decided that the Plan does not have to pay the remaining balance for the crown (D2740) provided on July 2, 2019 by an out of network dentist.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says you were not enrolled in the plan at the time of initial SNF admission. Therefore,
coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that if the provider is an inpatient acute care hospital,
inpatient rehabilitation facility or a long term care hospital, and the patient changes MA status during an
inpatient stay for an inpatient institution, the patient's status at admission or start of care determines liability.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of SNF care have not been met. Specifically, the records show you were initially admitted to a SNF
on February 28, 2020. Your enrollment with the Plan was effective on March 1, 2020. Therefore, we decided
that the Plan does not have to pre-approve skilled nursing facility (SNF) care.