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

We decided that the Plan does not have to pay forthe physician services provided on July 23, 2020 by an out of network provider.You asked the Plan to pay forthe physician services. You say that the services were medically necessary.The Plan denied your request. The Plan says you did not request 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 services at issue in this appeal. The Plan did not pre-approve the servicesat 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 physician services provided on July 23, 2020 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNurtec tablet.You asked the Plan to pre-approveNurtec tablet. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered benefit.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-approveNurtec tablet.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 13, 2020.
You asked the Plan to pay for the dental service. You say that the service you received on the date of service in this case was not an oral exam but an emergency temporary reconstruction of your tooth. You say that a piece of your tooth cracked off and the remainder of the tooth had to be sealed until a permanent solution could be applied. The Plan denied your request. The Plan says 2 oral exams are covered per calendar year. The Plan says that payment was made for the oral exams that you received on January 28, 2020 and March 4, 2020. The Plan says that the frequency limit for oral exams has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 2 oral exams per calendar year has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran emergency department visit (99282) on September 25, 2019.You asked the Plan to waive the copayment foran emergency department visit. Yousay that you did not receive services in the emergency room.The Plan denied your request. The Plan says the correct copayment was 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 $90 copayment for each emergency room visit. The case record shows that you received a preprocedural examination in the emergency department. You have been asked to pay a $90 copayment for an emergency department visit. An emergency department visit falls within the "Emergency Care" 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 haveto waive the copayment foran emergency department visit (99282) on September 25, 2019.Your complaint about being charged for an emergency department visit though your medical issue was not fully addressed or resolvedis 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forspinal canal injections provided on June 8, 2020, and June 15, 2020.You asked the Plan to waive the copayments forspinal canal injections. You say that you were only there for an hour and disagree with the charges.The Plan denied your request. The Plan says the claimswere 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 $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received a spinal canal injection on June 8, 2020. A spinal canal injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $295 copayment. You received a spinal canal injection on June 15,2020. A spinal canal injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $295 copayment.The total amount you owe is: $590. You have been asked to pay the total copayment amount of $590 for spinal canal injections. Spinal canal injections fallwithin 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 copayments forspinal canal injections provided on June 8, 2020, and June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image (X-ray) (D0230), recement crown (D2920), and preventative procedure (D1999) provided on August 17, 2020.
You asked the Plan to pay for intraoral - periapical each additional X-Ray, crown, and preventative procedure. You say that the services were medically necessary. The Plan denied your request. The Plan says you have exhausted your benefit maximum for intraoral X-rays and crowns and unspecified preventative procedure are not covered benefits of 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. Specifically, you are allowed one intraoral X-ray a calendar year. Records show you have previously received an intraoral x-ray this benefit plan year. Crowns and unspecified preventative procedures are not listed in the Plan's covered benefits. This means you are responsible for the cost of the procedures. Therefore, we decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image (X-ray) (D0230), recement crown (D2920), and preventative procedure (D1999) provided on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided by an out of network (OON) provider.

You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these 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 Plan does not have to pay foran office visit provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided.

You asked the Plan to pay for the lab services. The Plan denied your request. 

The Plan says the billed code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

We looked at the file and the rules. The records provided do not indicate the specimen was taken in an independent laboratory.Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay for the lab services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on May 12, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Per the Medicare guidelines HCPCS code G2025 services furnished between January 27, 2020, and June 30, 2020,need to be billed with additional codes GO466, G0467, G0468, G0469, G0470 or G2025 with modifier 95. Beginning July 1, 2020, FQHCs will only be required to submit with G2025 butmodifier 95 is not required (optional). The Plan states that as the date of services was May 12, 2020, this claim was billed incorrectly. 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 claimsubmitted is lacking additional codes required for payment of this service. Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forphysicianservices provided to the enrollee on May 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cystourethroscopyprovided on April 22, 2020 by an out of network provider.You asked the Plan to pay forthe cystourethroscopy. You say that the services were medically necessary.The Plan denied your request. The Plan says you did not request 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 services at issue in this appeal. The Plan did not pre-approve the service 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 cystourethroscopy provided on April 22, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forframes, purchases (V2020), progressive lens per lens (V2781), anti-reflective coating (V2750), scratch resistant coating (V2760), and encounter for examination of eyes and vision without abnormal findings (V2755) provided on July 11, 2020, by a non-contracted provider.You asked the Plan to pay forframes, progressive lens, anti-reflective coating, scratch resistant coating, and eye exam. You say that the services should be covered.The Plan denied your request. The Plan says the services are not covered by the plan when obtained out-of-network.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. The Plan covers these services only when received in-network..We looked at the file and the Plan's rules. You received care from a vision provider outside the Plan's network. Based on this information, we decided that the Plan's rules for coverage of frames, progressive lens, anti-reflective coating, scratch resistant coating, and eye exam have not been met.
Therefore, we decided that the Plan does not have to pay forframes, purchases (V2020), progressive lens per lens (V2781), anti-reflective coating (V2750), scratch resistantcoating (V2760), and encounter for examination of eyes and vision without abnormal findings (V2755) provided on July 11, 2020, by a non-contracted provider
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe definitive drug testing of 8-14 drug classes provided on July 26, 2020 billed with code G0481.You asked the Plan to pay forthe billed drug testing. You say that this testing was medically necessary and correctly billed.The Plan denied your request. The Plan says that the lab report does not show that between 8 and 14 drug classes were tested.The Plan mustfollow 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 G0481 is Drug test(s), definitive, 8-14 drug class(es), including metabolite(s) if performed.We find that CPT code G0481 is supported in the medical record. Specifically, review of the lab report shows that 10 separately billable drug classes were tested. Billable drug classes are based on separately billable tests in the CPT/HCPCS Handbook. Based on this information, we decided that Medicare rules for coverage of the billed drug testing have been met.Therefore, we decided that the Plan has to pay forthe definitive drug testing of 8-14 drug classes provided on July 26, 2020 billed with code G0481.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forcardiovascular risk assessment panel testing provided on May 12, 2020.You asked the Plan to pay forlab testing. You say that you are appealing with additional records.The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered by Medicare.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 documentation does not show that this panel testing was ordered by the enrollee's treating physician to guide therapeutic decision-making. Medicare does not cover this testing for screening purposes.Therefore, we decided that the Plan does not have to pay forcardiovascular risk assessment panel testing provided on May 12, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services provided to the enrollee from May 22, 2020, to May 28, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says these codes have a Status Indicator of "I" and are not payable on Medicare claims. 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, codes S9502 and S9500 have a status indicator that prevents payment on Medicare claims. Medicare uses other types of codes for this service. Medicare rules forcoverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forhome health services provided to the enrollee from May 22, 2020, to May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit provided on by an out of network (OON) provider.

You asked the Plan to pay for an outpatient visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these 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 Plan does not have to pay for an outpatient visit provided on June 3, 2020 by an out of network (OON) provide
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe cardiovascular lab testing provided on May 14, 2020.You asked the Plan to pay forthe cardiovascular lab testing. You say that this is shown to be medically necessary and should be covered.The Plan denied your request. The Plan says that this is excluded from Medicare coverage by Local Coverage Determination (LCD) L36523. As such, it cannot be overridden by plan-directed care.Please note: Maximus reviewed the LCD cited by the Plan. We find that the contractor that published this LCD does not have jurisdiction over Medicare Part B covered services for the State of Texas. As such, this LCD is not controlling.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.The enrollee was referred for the cardiovascular lab testing by a contract provider. The file does not show that the plan provided notice that the cardiovascular lab testing would not be covered. Under Medicare rules, this means the cardiovascular lab testing is considered approved by the plan.Therefore, we decided that the Plan has to pay forthe cardiovascular lab testing provided on May 14, 2020.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe outpatient surgery services and Part B drugs provided on September 9, 2020.You asked the Plan to waive the cost share forthe outpatient surgery services and Part B drugs. You say that you refuse to pay because of the price and you cannot afford the cost share.The Plan denied your request. The Plan says you were charged this coinsurance 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 Part B prescription drugs and a $235 copayment foroutpatient hospital services. You have been asked to pay 20% coinsurancefor the Part B drugsand a $235 copayment foroutpatient surgery. The outpatient surgery services fall within the outpatient surgery services category and the Part B drugs falls withinthe Part B prescription drugs category. This means that you have been asked to pay the correct amountsbased 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 cost share forthe outpatient surgery services and Part B drugs provided on September 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided on June 2, 2020.
You asked the Plan to pay for lab testing. You say that this testing was specifically requesting by the enrollee's physician. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. You have not submitted supporting records to the Plan. The Plan requested records, but these were not provided. Without this information, you have not furnished sufficient information to the Plan to justify payment of the claim as it has been billed. Based on this information, we decided that Medicare rules for coverage of lab testing have not been met. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that you did not need prior authorization to see the enrollee. The Plan denied your request. The Plan says prior authorization was not obtained as required.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 6, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant360 genetic testing provided on November 24, 2019.You asked the Plan to pay forthe Guardant360 genetic testing. 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 must follow Medicare rules. Medicare rules say that providersmust report services correctly. Providers must report services with the appropriate CPT code.In this case, Medicare guidelines say when billing for the Guardant360 molecular lab panel, procedure code 81479 is the only code available for billing. Based on this information, we decided that Medicare rules for coverage of the Guardant360 genetic testing have not been met.Therefore, we decided that the Plan does not have to pay forthe Guardant360 genetic testing provided on November 24, 2019.