Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on October 21, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan 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 physician services provided on October 21, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required, and four gingival irrigations provided on December 3, 2019 and December 11, 2019.
You asked the Plan to pay for the core buildup and four gingival irrigations. You say that you were charged for services that you did not want. The Plan denied your request. The Plan says these services are not covered 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 for the core buildup, including any pins when required, and four gingival irrigations provided on December 3, 2019 and December 11, 2019.
Your complaint about your issues with the provider and being misled by the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 24, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit provided on September 19, 2019.
You asked the Plan to waive the coinsurance for the office visit. You say that you are unable to pay. 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). Your contract with the Plan clearly says that you must pay 20% coinsurance for services obtained from a primary care provider. You have been asked to pay $15.58, which is 20% of the allowed amount for the office visit. The allowed amount is $77.89 (20% x $77.89 = $15.58). The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the office visit provided on September 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Targeted Genomic Sequence Analysis (Smart Genomics NGS Lymphoid) testing provided on May 7, 2019.

You asked the Plan to pay for the Targeted Genomic Sequence Analysis (Smart Genomics NGS Lymphoid) testing. You say that the genetic testing provided was medically necessary. The Plan denied your request. The Plan says the genetic testing provided was not medically necessary.

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 pay for the Targeted Genomic Sequence Analysis (Smart Genomics NGS Lymphoid) testing. Our reviewer says that the genetic testing provided was not medically necessary. Our physician reviewer found the enrollee is diagnosed with mantle cell lymphoma. Per NCCN guidelines mantle cell lymphoma 1.2020 page MANT-1, Tp53 may be helpful if transplant planned. The file does not show that transplant will be done. IGHV may be helpful in indolent disease. The enrollee has stage IV disease and needs treatment with chemo. In this case, the provided molecular testing is denied as will not help the enrollee with treatment decisions.

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 Targeted Genomic Sequence Analysis (Smart Genomics NGS Lymphoid) testing have not been met. Therefore, we decided that the Plan does not have to pay for the Targeted Genomic Sequence Analysis (Smart Genomics NGS Lymphoid) testing provided on May 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on October 18, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that that the provider should not be paid. 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 $45 copayment for each urgent care visit. You have been asked to pay a $45 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" 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 the urgent care visit provided on October 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to change responsibility forservices provided on July 31, 2019.You asked the Plan to change responsibility forthe ambulance services. You say that services that are not medically necessary are the enrollee's responsibility.The Plan denied your request. The Plan says the transport was not medically necessary.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, the provider did not submit their claim for payment with a GY modifier that indicates that the services provided were non-covered by Medicare. Because the provider is out-of-network, the plan cannot over-ride the claim.Therefore, we decided that the Plan does not have to change responsibility forservices provided on July 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power reducing air mattress (E0277) and heavy duty hospital bed (E0303).
You asked the Plan to pre-approve the power reducing air mattress and heavy duty hospital bed. You say that you are heavy set and has severe back problems. The Plan denied your request. The Plan says the requested services are not reasonable and necessary.
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 the power reducing air mattress and heavy duty hospital bed. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no deformity that would indicate a
need for positioning that would require a special bed. Elevation of the head and foot of the bed can be accomplished through use of pillows or wedge supports. A heavy-duty hospital bed is not medically necessary for this member. There is no history of pressure ulcers or inability to perform effective pressure reliefs. A power reducing air mattress is not medically necessary for this member. 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 power reducing air mattress and heavy duty hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve power reducing air mattress (E0277) and heavy duty hospital bed (E0303).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spinal injection provided on June 4, 2019.
You asked the Plan to waive the copayment for the spinal injection. You say that you say that the plan should pay more for this service. 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 $250 copayment for Medicare-covered surgery or other services at an in-network outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $250 copayment for the spinal injection. the spinal injection falls within the "Outpatient Surgery and Other Medical 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 the spinal injection provided on June 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out of network (OON) ophthalmologist.
You asked the Plan to pre-approve the referral. You say that you do not trust the in network doctors. The Plan denied your request. The Plan says that the services are available in 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 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 a referral to an out of network (OON) ophthalmologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an Eye Exam (92014) provided onDecember 20, 2019.
You asked the Plan to pay for the eye exam. You say that you thought the eye exam was covered. The Plan denied your request. The Plan says coverage for eye exams is limited to once a year.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The plan covers one eye exam a year. Records show an eye exam was already rendered on January 9, 2019. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for an Eye Exam (92014) provided on December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chronic care management provided on September 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for chronic care management. You say that since the member was in a nursing facility, the doctor was not responsible to get authorization. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring facility 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 chronic care management provided on September 16, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Osteogenesis Imperfecta (OI) Panel
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was found to have osteoporosis on bone mineral density screening. It is noted that she has a history of six fractures in childhood, but there have been no fractures since childhood. X-rays of the lumbar spine are normal. Genetic testing for OI is not definitive. Negative studies do not exclude the diagnosis of OI, and there are OI types that are not associated with the mutations that are tested. Furthermore, it has not been demonstrated that the results of such testing will directly impact the management of the enrollee in this case. The OI testing is 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-approve the Osteogenesis Imperfecta (OI) Panel
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 1, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory tests. You say that you were informed that your providers were in-network with this Plan. 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 July 1, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on November 19, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on November 19, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound provided on August 3, 2019.
You asked the Plan to pay for the ultrasound. 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 an ultrasound provided on August 3, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on November 14,
2019 to December 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physical therapy services. You say that you would like the Plan to reconsider
their denial of payment. The Plan denied your request. The Plan says the services received were neither
emergent nor urgent and prior authorization was not obtained to seek out-of-network care. The Plan states there
were equally qualified and accessible physical therapy providers available to you.
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 physical therapy services provided on
November 14, 2019 to December 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forassisted living services provide on September 20, 2019 by an out of network (OON) provider.You asked the Plan to pay forassisted living services. You say that since the member is in a nursing facility, the doctor is not responsible to get authorization.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring facility 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 thePlan does not have to pay forassisted living services provide on September 20, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe out of area cataract surgery provided on October 29, 2019.You asked the Plan to pay forthe out of area cataract surgery. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  We looked at thefile and Medicare rules. The file does not show that the cataract surgery was provided due to an unforeseen illness or condition and does not show that the services were pre-approved. Based on this information, we decided that Medicare rules for coverage of the out of area cataract surgery have not been met.Therefore, we decided that the Plan does not have to pay forthe out of area cataract surgery provided on October 29, 2019.