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

We decided that the Plan does not have to pay for the laboratory services provided on October 19, 2020 by a non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 provided on October 19, 2020 by a non-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on June 1, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for physician 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 by the member's primary care physician. The Plan says that the referring provider 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 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 June 1, 2020 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99285) provided January 17, 2021.
You asked the Plan to pay for the emergency room services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99285 is not supported in the medical record. Specifically, insufficient documentation was submitted to support the code billed. The plan requested additional documentation and it was not received. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services (99285) provided January 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on October 22, 2020.
You asked the Plan to pay for the durable medical equipment. 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. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on October 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services with dental code D7210 provided on March 22, 2021.

You asked the Plan to pay for dental code D7210. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D7210 is not covered under the Plan's supplemental dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, dental code D7210 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services with dental code D7210 provided on March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping mate (D5214).

You asked the Plan to pre-approve a lower partial denture. You say that your current partial denture is broken, and you need a new one to eat. The Plan denied your request. The Plan says you have exceeded frequency limits for this service.

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 a lower partial denture once every five plan years. 

We looked at the file and Medicare rules. The Plan provided documentation showing that a lower partial denture was previously covered on April 22, 2019. Based on this information, we determined that the Plan's coverage limits for a lower partial denture would be exceeded. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping mate (D5214).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an endoscopy (43239) provided April 1, 2021.

You asked the Plan to waive the copayment for the endoscopy. You say that the copayment should be waived. 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 $300 copayment for outpatient hospital surgical services. 

You have been asked to pay a $300 copayment for the endoscopy. The endoscopy falls within the outpatient hospital surgical 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 an endoscopy (43239) provided April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit and injection (99214, 96365, J1493) provided January 29, 2021.
You asked the Plan to waive the copayment for the office visit and injection. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 $40 copayment for specialist visits and a 20% coinsurance for Part B Drugs. You have been asked to pay a $40 copayment for the office visit and a 20% coinsurance for the injection. 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 an office visit and injection (99214, 96365, J1493) provided January 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 11, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services 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 test at issue in this appeal, a cardiovascular risk assessment 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 laboratory services rendered on January 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ultrasound and duplex scan provided on March 10, 2021.
You asked the Plan to waive the copayments for the ultrasound, abdominal (76700) and duplex scan (93976). You say that the provider should bill as a single service, so you are not responsible for two copays. The Plan denied your request. The Plan says the Medicare allowed amount for the services is $109.02, therefore you are charged less than the required copayment.
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 $125 copayment for each Other Outpatient Diagnostic Tests. You have been asked to pay a $109.02 copayment for the ultrasound, abdominal (76700) and the duplex scan (93976). The ultrasound, abdominal (76700) and duplex scan (93976) fall within the Other Outpatient Diagnostic Tests 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 for the ultrasound and duplex scan provided on March 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker (E0144) provided on February 7, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for a walker. You say that you were told you could buy this anywhere. The Plan denied your request. The Plan says this was 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 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 a walker (E0144) provided on February 7, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from February 24, 2021, through February 10, 2021.

You asked the Plan to waive the copayment for physical therapy. You say that the copayment should be $5. The Plan denied your request. The Plan says the copayments applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for Medicare-covered physical therapy (in-person or virtual) visits.

You have been asked to pay a $15 copayment for each physical therapy visit. The total amount you owe is $75 ($15/visit x 5 visits = $75). Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided from February 24, 2021, through February 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on December 26, 2020.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that the service at issue was medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on December 26, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on December 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services with dental codes D7550 and D0140 provided on February 8, 2021.

You asked the Plan to pay for dental codes D7550 and D0140. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D7550 and D0140 are not covered under the Plan's supplemental dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, dental codes D7550 and D0140 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services with dental codes D7550 and D0140 provided on February 8, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve for the individual psychotherapy services (90836).
You asked the Plan to pre-approve for the psychotherapy services. You say that based on the coordination of care that to provide effective TMS services to the enrollee, you must provide medication management with therapy to determine the appropriate level of TMS treatment of document progress. The Plan denied your request. The Plan says this provider is not a Medicare contracted provider.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pre-approve for the individual psychotherapy services (90836).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided on February 16, 2021.
You asked the Plan to waive the coinsurance for radiation therapy services. You say that you could have done surgery for free but was advised of radiation treatment. You say that you were never told there was 20% coinsurance. 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 per visit for radiation therapy.
You have been asked to pay $63.65, which is 20% of the allowed amount for radiation therapy services. The
allowed amount is $318.23 (20% x $318.23 = $63.65). Radiation therapy services fall 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 services provided on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride - excluding varnish
(D1208) provided October 26, 2020.

You asked the Plan to pay for the fluoride treatment. You say that your services should be covered. The Plan
denied your request. The Plan says the claims from this date have been re-processed as in-network however
this service is not covered under your dental 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
topical application of fluoride - excluding varnish (D1208) provided October 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81210, 81206, 81275, 81235) provided January 19, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 81210, 81206, 81275, & 81235 is not supported in the medical record. Specifically, the date of service on the claim does not match the date of service on the records. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81210, 81206, 81275, 81235) provided January 19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the moderate sedation services provided on September 21, 2020.
You asked the Plan to pay for the moderate sedation services (99152) for the SI joint injection. You say that moderate sedation was medically necessary for the procedure. The Plan denied your request. The Plan says that moderate sedation was not medically reasonable and necessary for the sacroiliac joint injection.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 moderate sedation services (99152) for the SI joint injection. Our reviewer says that the services are considered medically reasonable and necessary in this case. Our physician reviewer found the Plan's policy specifically allows for moderate sedation for SI joint injection. The request was medically reasonable and 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 moderate sedation services (99152) for the SI joint injection. have been met. Therefore, we decided that the Plan has to pay for the moderate sedation services provided on September 21, 2020.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
You asked the Plan to pre-approve Synvisc-One. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Synvisc-One. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has pain related to osteoarthritis of the knee, diagnosis confirmed with imaging studies. The enrollee has failed conservative treatment. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc. The documentation does not support that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.