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

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on August 20, 2019.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says the services were not authorized.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 providersonly 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 forthe medical services provided to you by an out-of-network provider on August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not have to waive the copayments forintravenous infusions provided from August 8, 2019 to August 15, 2019.You asked the Plan to waive the copayments forintravenous infusions. You say that you disagree with the charges.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 $200 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.You received intravenous infusions at an outpatient hospital facility from August 8, 2019 to August 15, 2019 for a total of 7 services. Therefore, you are responsible to pay the total allowed amount of $1,245.65, which is less than the total copayment amount. You have been asked to pay $1,245.65 for intravenous infusions. Intravenous infusions fall within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have beenasked 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 copayments forintravenous infusions provided from August 8, 2019 to August 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveInvokana for the enrollee.You asked the Plan to pre-approveInvokana. You say that the enrollee has triedand failed Jardiance.The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs 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-approveInvokana for the enrollee. Benefits for Invokanamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forradiation therapy provided by from September 3, 2019 to September 24, 2019.You asked the Plan to waive the coinsurance forradiation therapy. You say that you were under the impression that the services would be fully 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 20% coinsurance for radiation therapy.You received radiation therapy from September 3, 2019 to September 24, 2019. The total allowed amount is $7,801.20 and 20% of that is $1,560.24.  You have been asked to pay the total coinsurance amount of $1,560.24 for radiation therapy. Radiation therapy 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 coinsurance for radiation therapy provided b from September 3, 2019 to September 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forlab services provided to the enrollee on October 1, 2019You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe enrollee's primary care physician did not refer for these out-of-network services.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 Plandoes not haveto pay forlab services provided to the enrollee on October 1, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foran oral evaluation (D0120), prophylaxis (D1110), and fluoride application (D1208) provided on June 26, 2019.You asked the Plan to pay foran oral evaluation, prophylaxis, and fluoride application. You say that this was medically necessary.The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicarecoverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay foran oral evaluation (D0120), prophylaxis (D1110), and fluoride application (D1208) provided on June 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 30, 2019 to the enrollee by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-participating 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 casesinvolving 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 referring provider 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 forthe medical services provided on October 30, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing provided to the enrollee on September 10, 2019.You asked the Plan to pay forthe testing services. The Plan denied your request. The Plan says the documentation did not include a valid physician order or lab requisition stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.We find that CPT code 80307 and G0482are not supported in the medical record. Specifically, there were insufficient records to show the results of this testing would be used to determine a specific diagnosis or a specific treatment strategy for disease or illness present at the time of service. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay forthe drug testing provided to the enrollee on September 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.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 requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for end-stage chronic obstructive pulmonary disease (COPD). 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. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvestem cell injections of the lumbar facets.You asked the Plan to pre-approvethe Stem cell injections of the lumbar facets. You say that the records provided support the need for the injections requested.The Plan denied your request. The Plan says the records do not show that the enrollee meets the criteria for the repeat injection services being requested.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 Stem cell injections of the lumbar facets. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain and had an SCS implanted. The enrollee had both generator and lead failure. Subsequently, the enrollee had a panel lead placed but that also did not help. The enrollee has tried physical therapy, Chiropractic care, TENS, heat, and medication trials with opiates, anti-convulsants, muscle relaxants, Toradol and Tylenol. The enrollee has had radiofrequency ablation of the lumbar facet in the past. Stem cell injections of the lumbar facets are considered an experimental and investigational approach to treatment.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 Stem cell injections of the lumbar facets have not been met.Therefore, we decided that the Plan does not have to pre-approvestem cell injections of the lumbar facets.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee on September 20, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe out-of-network services. You say that the enrollee's medication was due to run out prior to his new primary physician visit.The Plan denied your request. The Plan says the enrollee is required to obtain covered services from 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 services at issue in this appeal. The Plan did not pre-approve the services. 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 to the enrollee on September 20, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe surgical services to be provided by an out of network (OON) hand/microvascular surgeon.You asked the Planto pre-approvethe OON surgical services. You say that you have been waiting for this surgery for years and have extreme pain and are not able to work. This provider is at the top of his field and will have the best chance of reducing your pain and increasing function.The Plandenied your request. The Plansaysupon review, it was found that your network has a tertiary level provider at a Medical Center. He has similar expertise in hand and microsurgery as the requested OON provider. As the required expertise is available from a network provider, the OON referral is not necessary.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 Plandoes not haveto pre-approvethe surgical services to be provided by an out of network (OON) hand/microvascular surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for discharge day management services (99239) provided on April 26, 2019.You asked the Plan to pay for the discharge day management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include a hospital discharge day management note with a documented duration of time of 31 minutes or more for the billed date of service April 26, 2019.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 CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the record. Specifically, the record does not include a hospital discharge summary for April 26, 2019. The billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for discharge day management services (99239) provided on April 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long-term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansayscare can continue to be received at the current inpatient hospital.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 requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for ischemic colitis. The enrollee underwent colorectal surgery. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. 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. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-termcare needs.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 Plandoes not haveto pre-approveadmission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 22, 2019 by an out of network (OON) provider.You asked the Plan to pay forlaboratory testing. You say that the specimen was taken in a participating provider's office and sent to you.The Plan denied your request. The Plan says the denial of payment for this service 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 haveto pay forthe medical services provided on October 22, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forresin-based composite -two surfaces, posterior (D2392) provided on October 31, 2019.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plandenied your request. The Plan says the service is not a covered benefit under the plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forresin-based composite -two surfaces, posterior (D2392) provided on October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foreyeglasses (99213) provided on November 18, 2019.You asked the Plan to pay forthe eyeglasses. You say that two pairs of glasses were provided and should be covered.The Plan denied your request. The Plan says the charges exceed the benefit provided for glasses furnished by out-of-network providers.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. Plan rules allow for $90 annually for eyeglasses. The services you asked the Plan to pay for are considered routine vision services or eyewear. The total charges exceed the $90 plan benefit. The amount over the $90 does not meet coverage criteria.Therefore, we decided that the Plan does not have to pay foreyeglasses (99213) provided on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fororal hygiene instructions (D1330 x 2) and 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided on October 18, 2019 by an out-of-network provider.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the services are not a coveredbenefit under the plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefitin excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered.Therefore, we decided that the Plan does not have to pay fororal hygiene instructions (D1330 x 2) and 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided on October 18, 2019 by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care (99308) provided by out of network (OON) provider on July 18, 2019.You asked the Plan to pay forthese services. You say that you are requesting reconsideration of the Plan's denial for payment of the services provided.The Plan denied your request. The Plan says the services were provided by an out of 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 provider in this case is not anetwork 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 thesubsequent nursing facility care (99308) provided on July 18, 2019.