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

We decided that the Plan does not have to pay for specialist services provided on August 25, 2020 by an out of network (OON) provider.

You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is 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 had network providers available who could have provided 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 specialist services provided on August 25, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services (90792) provided on January 29, 2019.

You asked the Plan to pay for the psychiatric services. You say that you would like reconsideration because you did not receive proper notice of the member's benefit determination. The Plan denied your request. The Plan says this claim was submitted past the 12 month timely filing time frame.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the psychiatric services was not filed until September 3, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services (90792) provided on January 29, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve post removal for tooth #30.
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan
denied your request. The Plan says that the requested service is either not medically necessary, reasonable, or
both.
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. The Plan covers the dental
services when the services are medically necessary and reasonable.
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 dental services. Our reviewer says
that the requested services are not medically reasonable or necessary. Our physician reviewer found the
removal of the post in the distal canal (D2955) is necessary to gain access to the distal canal in the re-treatment
of the failing root canal in tooth #30.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to
pre-approve post removal for tooth #30.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 22, 2019 by an out of network (OON) provider.

You asked the Plan to pay for an integrated biopsychosocial assessment. You say that you disagree with this adverse determination and request a clinical review based on medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that these services could have been provided 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 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 had network providers available who could have provided 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 physician services provided on November 22, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuropsychological testing for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your
request. The Plan says this testing is not considered reasonable and necessary when repeated when not required
for medical decision-making.
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 testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the request for neuropsychological testing is not medically necessary or reasonable as information
presented in 2019 is sufficient for the decision-making process for treatment of this enrollee.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pre-approve neuropsychological testing for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) for tetanus vaccination (90715) immunization administration (90471) provided February 13, 2019.

You asked the Plan to pay for the office visit. You say that you were not made aware that your insurance would not pay for this bill. You would like a refund of your amount paid out. The Plan denied your request. The Plan says a tetanus vaccination is not covered as a preventive service because it is excluded by the plan.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the office visit. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the office visit. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99214) for tetanus vaccination (90715) immunization administration (90471) provided February 13, 2019. 

Benefits for the office visit may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a lithotripsy provided on September 3, 2020.

You asked the Plan to waive the copayment for a lithotripsy. You say that you disagree with the charges because the procedure had to be done a second time. 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, including services provided at hospital outpatient facilities. 

You have been asked to pay a $200 copayment for a lithotripsy. A lithotripsy 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 a lithotripsy provided on September 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on August 7, 2020.

You asked the Plan to pay for CxBladder testing. You say that this is a covered service. The Plan denied your
request. The Plan says this was not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are
non-covered.

We looked at the file and Medicare rules. The test at issue is not covered. Based on this information, we
decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that
the Plan does not have to pay for CxBladder testing (0012M) provided on August 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown for tooth #9 for the enrollee.

You asked the Plan to pre-approve the crown. You say that this is medically necessary. The Plan denied your request. The Plan says there is no radiographic evidence or an explanatory provider narrative describing the presence of marginal decayor other significant clinical breakdown that would support the need for crown replacement.

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 crown. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is requesting a replacement crown on tooth #9. There is an existing crown on a root canal treated #9 with the provided x-rays not showing any notable marginal defects/decay. The plan provides that for existing crowns that coverage would be denied when "an existing crown is present with an open margin and no decay; an existing crown is present with chipped or fractured porcelain without decay." In this instance there is no defect seen around crown #9 and no noted porcelain fractures. There is no documentation that indicated there would have been any marginal decay present in tooth #9. Given the documentation provided and the Plan criteria, there is no necessity for a replacement crown 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 the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown for tooth #9 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve dental services (D6241 on tooth #3) 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 that the records did not clearly show why this service was needed.
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. The Plan covers the services when the services are medically necessary and reasonable. 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 the requested services are medically reasonable or necessary. Our physician reviewer found dental implants are in place in area in areas #2 and 4. It is reasonable and necessary to place a 3 unit implant supported bridge replacing missing tooth #3 with a pontic (D6241) using the implants in areas #2 and 4 as abutments. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-approve dental services (D6241 on tooth #3) for the enrollee.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral nutrition (Ensure high protein drinks).
You asked the Plan to pre-approve the services. You say that this was recommended by the surgeon. The Plan
denied your request. The Plan says treatment of morbid obesity is not a covered indication.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found you are able to eat a regular diet. There is insufficient support for this request as you do not have a
significant need for a liquid diet, does not require tube feeds at this point, and has not been described to have
tried eating real food to help with weight loss. Ensure is not indicated for weight loss and will be considered
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 enteral nutrition (Ensure high protein drinks).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says a review of the current medical literature indicates that this service is considered
experimental and investigational.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the spacer device is experimental. More research is needed to show safety and efficacy of the device.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 16, 2020, by an out of network provider.
The enrollee asked the Plan to pay for computed tomography scans of the thorax and of the abdomen and pelvis. The enrollee says that they were told by the provider that these services were preauthorized. The Plan denied the enrollee's request. The Plan says rules for payment have not been met.
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 had network providers available who could have provided 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 June 16, 2020, by an out of network provider.
The enrollee's complaint about receiving erroneous or ambiguous information about preauthorization from the provider is not a valid appeal for medical coverage. This part of the enrollee's 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 respiratory panel rendered on February 18, 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 testing is 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 test at issue in this appeal, a respiratory panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the respiratory panel rendered on February 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a colonoscopy provided on October 14, 2020.
You asked the Plan to waive the coinsurance for a colonoscopy. You say that this was a preventative colonoscopy and 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 30% coinsurance for out-of-network Medicare preventative services. You received a colonoscopy from an out-of-network provider on October 14, 2020. Therefore, you are responsible to pay your share of the out-of-network services. The total allowed amount is $905.22 and 30% of that is $271.57. You have been asked to pay the total coinsurance amount of $271.57 for a colonoscopy. A colonoscopy falls within the Medicare preventative 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 coinsurance for a colonoscopy provided on October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography professional component provided on August 21, 2020.
You asked the Plan to pay for computed tomography professional component. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee was inpatient during this date of service therefore the POS code is incorrect.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate POS code. We find that the enrollee received the technical component while inpatient therefore the POS code submitted is incorrect. Based on this information, we decided that Medicare rules for coverage of computed tomography professional component have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography professional component provided on August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hepatitis A vaccine (90632) and administration (90471)
provided on September 9, 2020.
You asked the Plan to pay for a hepatitis A vaccine and administration. You say that this should be covered.
The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of the enrollee's
prescription drug plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a hepatitis A vaccine
and administration. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to a hepatitis A
vaccine and administration. Therefore, we decided that the Plan does not have to pay for a hepatitis A vaccine
(90632) and administration (90471) provided on September 9, 2020.
Benefits for a hepatitis A vaccine and administration may be available under Medicare Part D. Contact the Plan
that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81001, 87086, 36415, 80053) provided on October 16, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON laboratory services. You say that these services should be covered. The Plan denied your request. The Plan says these 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 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 had network providers available who could have provided 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 laboratory services (81001, 87086, 36415, 80053) provided on October 16, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88312) provided on August 31, 2020 by an out of network (OON) provider.

You asked the Plan to pay for OON laboratory services. You say that this should be covered. The Plan denied your request. The Plan says this was 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 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 had network providers available who could have provided 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 laboratory services (88312) provided on August 31, 2020 by an out of network (OON) provider.