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

We decided that the Plan does not have to reimburse you for the repair of a broken denture (D5510) provided on May 10, 2019.
You asked the Plan to reimburse you for the dental service. You say that you were initially referred to a provider that does not do denture repair. You say that that provider referred you to another provider that does do denture repair. You also say that you are disable veteran and only receive a check once per month. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says services that you receive out of network are not covered. The Plan also says you will be responsible for all costs related to those 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, dental services that you receive out of network are not covered. Therefore, we decided that the Plan does not have to reimburse you for the repair of a broken denture (D5510) provided on May 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on November 11, 2019.
You asked the Plan to waive the copayment for arthrocentesis. You say that you do not understand why the charges are not covered. 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 $400 copayment for outpatient hospital surgery services. You received arthrocentesis on November 11, 2019. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $249.35, which is less than the $400 copayment. You have been asked to pay $249.35 for arthrocentesis. Arthrocentesis 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 for arthrocentesis provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception request for an ankle foot orthosis (L1960), soft interface (L2820), and a lower extremity addition (L2275) to be rendered by an out of network (OON) provider.
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's denial for an in-network exception request due to the patient's need for a custom fabricated ankle foot orthotic. The Plan denied your request. The Plan says the items requested are available with an in-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve an in-network exception request for an ankle foot orthosis (L1960), soft interface (L2820), and a lower extremity addition (L2275) to be rendered by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for pulmonary diagnostic testing provided on December 6, 2019.
You asked the Plan to waive the copayment for pulmonary diagnostic testing. You say that you never had an appointment and did not receive services. 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 an $80 copayment for diagnostic procedures and tests. The medical records show that you received pulmonary diagnostic testing on December 6, 2019. Therefore, you are responsible to pay the $80 copayment. You have been asked to pay an $80 copayment for pulmonary diagnostic testing. Pulmonary diagnostic testing falls 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 for pulmonary diagnostic testing provided on December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve POV, group 1 standard, patient weight capacity up to
and including 300 pounds (CPT Code K0800).
You asked the Plan to pre-approve the POV. You say that the service is medically necessary.
The Plan denied your request. The Plan says the Medicare rules have not been 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 the POV. Our physician reviewer found
it's not clear if cane or walker is not sufficient for your activity of daily living. The patient is not noted to have
inability to utilize a lesser device (lightweight manual wheelchair, standard manual wheelchair, or use of a
walker). Therefore, this request is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the POV have not been met. Therefore, we decided that the Plan does not have
to pre-approve POV, group 1 standard, patient weight capacity up to and including 300 pounds (CPT Code
K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 21, 2019 by a non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 21, 2019 by a non-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services for the enrollee.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says further visits will need updated clinical information to make sure continued services are still needed.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has already had physical therapy on a long term basis and is a long-term care resident and would have caregiver assistance available. Physical therapy provided in excess of what is medically necessary may promote dependence on therapy provided treatments rather than a regularly performed home exercise program. A daily home exercise program with caregiver assistance would best meet this member's needs. The additional visits already approved should be adequate in terms of completing caregiver training and establishing an effective home exercise/maintenance program with revision if necessary. A reassessment after completing the treatments that were authorized would be expected before requesting additional therapy. For these reasons, the remaining therapy requested is not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on December 13, 2019, December 17, 2019 and December 23, 2019. You asked the Plan to pay for the psychotherapy 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 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 psychotherapy services provided on December 13, 2019, December 17, 2019 and December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 26, 2019 by a
non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-network provider without prior authorization.
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 September 26,
2019 by a non-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection, blood draw, and laboratory testing provided on
December 13, 2019.
You asked the Plan to pay for the physician services. You say that the claim has not been paid in full or
according to the terms of the contract. The Plan denied your request. The Plan says the enrollee's Medicare
hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to
the date of discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also
covers attending physician services and all care unrelated to the terminal illness until the first day of the month
following the month in which hospice was revoked or discharged.
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 the injection, blood draw, and laboratory testing provided on
December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 7, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 Plandid 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 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the tissue exam and immunohistochemistry rendered on January 15, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were reported in a facility setting.
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately payable when furnished in different payment localities. We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different payment localities. 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 pay for the tissue exam and immunohistochemistry rendered on January 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the prostatectomy provided from October
30, 2019 through October 31, 2019.
You asked the Plan to waive the copayment for the prostatectomy. You say that you were informed you were
supposed to be admitted as an inpatient. You say that you are not responsible for the additional $25. 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 $400
copayment for outpatient surgery provided at an outpatient hospital facility.
You have been asked to pay a $400 copayment for the prostatectomy. The prostatectomy falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The records show that this was an outpatient 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 prostatectomy provided from October 30, 2019 through October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services you provided on November 1, 2019.
You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 surgical pathology services you provided on November 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial nursing facility care provided on December 11, 2019.
You asked the Plan to pay for the initial nursing facility care. 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 and the referring provider in this case are not network providers 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 initial nursing facility care provided on December 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 20, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an
independent laboratory; however, the file shows that the specimen was obtained in an office setting and should
have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug
testing rendered on November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for pulp vitality test, tooth 19 (D0460) limited oral exam, tooth 19 (D0140) cone beam computed tomography (D0381) periapical first x-ray (D0220) and periapical each additional x-ray (D0230) provided January 7, 2020.You asked the Plan to pay forthe dental services. You say that the dentist told you that the tooth had to be pulled. They gave you an x-ray, a shot of Novocain for pain and sent you next door. You had no control of this and do not have the money to pay this bill.The Plan denied your request. The Plan says these services are 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 pay forpulp vitality test, tooth 19 (D0460) limited oral exam, tooth 19 (D0140) cone beam computed tomography (D0381) periapical first x-ray (D0220) and periapical each additional x-ray (D0230) provided January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial nursing facility care provided on January 9, 2020.
You asked the Plan to pay for the initial nursing facility care. 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 and the referring provider in this case are not network providers 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 initial nursing facility care provided on January 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 10, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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 the Plan. The Plan did not pre-approve the
laboratory 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 laboratory services provided on December 10, 2019.