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

We decided that the Plan does not have to pre-approve the Xiidra 5% ophthalmic solution.
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the patient as it targets eye inflammation caused by dryness. The Plan denied your request. The Plan says the member has a medical (MA) only policy with the Plan, not a Prescription Drug Plan (PDP). Therefore, drug coverage is limited to Medicare Part B covered drugs. This medication is not a covered benefit under the member's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Xiidra 5% ophthalmic solution.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 4, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition.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 looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 pay for the drug testing services provided to the enrollee on September 4, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve consultation and treatment with an out of network (OON) glaucoma specialist.
You asked the Plan to pre-approve the OON glaucoma specialist services. You say that the enrollee's disease has progressed and she requires management by a fellowship-trained glaucoma specialist. The Plan denied your request. . Since there are network providers, there is no need to approve the OON care.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The plan contract says that enrollees must use contract providers. We were able to confirm that the Plan does not have contract providers located within reasonable distance and travel time from the enrollee's home who can provide glaucoma specialist services. The requested OON provider is about 100 miles away from the enrollee's home. The in network provider is about 130 miles away, and about 25 minutes more driving time. Review of the website does not note that he has fellowship training glaucoma. Although another in network doctor does have this training, this office is over three hours away from the enrollee's home. Under Medicare rules, this means that contract providers are not accessible to the enrollee. Therefore, we decided that the Plan has to pre-approve consultation and treatment with an out of network (OON) glaucoma specialist.
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 the medical services to be provided by an out of network provider for pain management.
You asked the Plan to pre-approve a second opinion consultation. You say that you would like the opportunity to go talk to a pain management outside of your network. You say that you will come back  for further treatment based upon the results of the consultation. The Plan denied your request. The Plan says the services that are being requested can be offered within network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network provider for pain management.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on March 25, 2019.
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 claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an
independent laboratory; however, the file shows that the specimen was obtained in an office setting and should
have been billed with POS code 11.
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on March 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 30, 2018 through November 8, 2018 provided by an out-of-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were covered with the Plan at this time and you do not understand why this was not paid. You state that you are wondering why the laboratory services for November 12, 2018 and November 18, 2018 were not paid because you have insurance. The Plan denied your request. The Plan says they approved payment of the laboratory charges from November 12, 2018 and November 19, 2018 because a participating provider sent the lab charges to a non-participating hospital.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from October 30, 2018 through November 8, 2018 provided by an out-of-network provider. You are asked to pay a $275 copayment per day for inpatient hospital care for days 1-5. 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 inpatient hospital care from October 30, 2018 through November 8, 2018 provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing home service provided on December 5, 2018.
You asked the Plan to pay for nursing home service. You say that you are appealing with attached documents.
The Plan denied your request. The Plan says the denial of payment for this service is correct, because this
provider is not eligible to participate in Medicare and service could have been provided by a Medicare-contracted
provider.
The Plan must follow Medicare rules. Medicare rules say that no provider shall receive payment for services
unless the provider is enrolled in the Medicare program.
We looked at the file and Medicare rules. The Provider is not enrolled in the Medicare program, therefore
services received from this provider are not eligible for payment. Based on this information, we decided that
Medicare rules for coverage of nursing home service have not been met. Therefore, we decided that the Plan
does not have to pay for nursing home service provided on December 5, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99213), the coinsurance for an aspiration and/or injection of large joint or joint capsule (20610), and injections (J7321, J3490) provided from August 14, 2019 to September 11, 2019.
You asked the Plan to waive the copayment for an office visit, and the coinsurance for an aspiration and/or injection of large joint or joint capsule, and injections. You say that you are appealing the claim stating the Plan should have sent the benefit information with the approval for services. You were not told until after you had the services that you would have copayments and coinsurance amounts and you cannot afford this. The Plan denied your request. The Plan says that an office visit has a $15 copayment and injections have a 20% coinsurance.
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 physician services, and a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a $15 copayment for an office visit, and a 20% coinsurance for an aspiration and/or injection of large joint or joint capsule, and injections. These services fall within the physician services with a specialist and Medicare Part B prescription drugs benefit category. Between August 14, 2019 to September 11, 2019, there were 4 visits. Each visit incurred a copayment for an office visit and a coinsurance for Medicare Part B prescription drugs ($15 x 4 = $60, and $29.94 x 4 = $119.76. Therefore $60 + $119.76 = $179.76). 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 (99213), the coinsurance for an aspiration and/or injection of large joint or joint capsule (20610), and injections (J7321, J3490) provided from August 14, 2019 to September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvediabetic supplies for the enrollee to be provided by a non-preferred provider.You asked the Plan to pre-approvethe requested items. You say that the enrollee needs tests strips to match his current meter.The Plan denied your request. The Plan says the requested test strips are not preferred strips for 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 covers any blood glucose monitors and test strips specified within the preferred brand list above.The requested brand in this case is not a preferred brand with the Plan. The Plan has preferred brands available who can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approvediabetic supplies for the enrollee to be provided by a non-preferred provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on June 26, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say you can't pay your bills on time. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for each in-network one-way Medicare covered trip. You have been asked to pay a $100 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance ride provided on June 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the debridement service provided on July 18, 2019.
You asked the Plan to reduce the copayment for the debridement service. You say that you had the same treatment five times and were not charged a copayment. You say this copayment should be waived. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $400 copayment for per date of service at an outpatient hospital facility. The enrollee has been asked to pay a $400 copayment for the debridement service. The debridement service falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for debridement service provided on July 18, 2019.
Your complaint about billing fraud is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast biopsy provided on November 18, 2019.
You asked the Plan to waive the copayment for a breast biopsy. You say that you already paid the $45 copayment and disagree with the higher chargers. 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 members must pay a $350 copayment for outpatient surgery services provided in an outpatient hospital facility. You received a breast biopsy at an outpatient hospital facility on November 18, 2019. Therefore, you are responsible to pay the $350 copayment. You have been asked to pay a $350 copayment for a breast biopsy. A breast biopsy 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 breast biopsy provided on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient clinic visit provided on May 14, 2019.
You asked the Plan to waive the copayment for the outpatient clinic visit. You say that you were told you should only have a specialist copayment. You were told if the clinic did bill you then you should contact a Plan representative. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $450 copayment for surgery services at an in-network outpatient hospital. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $450 copayment for the surgery services at an outpatient hospital.
You have been asked to pay a $92.78 copayment for the outpatient clinic visit. The outpatient clinic visit 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 the outpatient clinic visit provided on May 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the destruction of facet joint nerves (64635 and 64636) provided on December 30, 2019. You say that you would like reconsideration because you were told authorization was not required. The Plan denied your request. The Plan says non-urgent services should be from network providers who are contracted with the member's healthplan and listed in the Provider Directory.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on December 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to the physician at the in-network rate. 
 
You asked the Plan to pre-approve these services. You say that you are an established patient of this provider. The Plan denied your request. The Plan says the services are available from network providers at the in network rate. 
 
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 $60 copayment for each out-of-network specialist visit for Medicare-covered services.  
 
The physician is not a network provider with the Plan. If you choose to receive services from this provider, you will be asked to pay a $60 copayment for these services. These services fall within the out-of-network specialist visit for Medicare-covered services benefit category. This means that you will be 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. The Plan has network providers from which you may receive services at the in-network rate. Therefore, we decided that the Plan does not have to pre-approve a referral to the physician  at the in-network rate.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on May 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient lab work. You say that the referring physician is in-network with the Plan. The Plan denied your request. The Plan says the referring provider is not a participating provider. The Plan says that no prior authorization was obtained.
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 outpatient lab work provided on May 18, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the maxillary partial denture, mandibular partial denture, and scaling in presence of generalized moderate or severe gingival inflammation.
You asked the Plan to pre-approve the maxillary and mandibular partial dentures and scaling. You say that you are in pain and you feel that these procedures are imperative. The Plan denied your request. The Plan says these services are not covered benefits and are excluded under the 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the maxillary partial denture, mandibular partial denture, and scaling in presence of generalized moderate or severe gingival inflammation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204), and an ultrasound study of arteries of both arms and legs (93923) provided on August 20, 2019 by the out of network provider.
You asked the Plan to pay for an office visit and an ultrasound. You say that the patient relocated suddenly from the Jacksonville area to Thomasville, Georgia. You say that due to the amount of pain she was in, she was not able to establish primary care or change her insurance plan before being seen in your office. The Plan denied your request. The Plan says the non-urgent services are not authorized because the physician is a non-network provider who does not work with the Plan, and the member self-directed for services. The Plan says that the member's primary care physician (PCP) did not refer for services. The Plan also says it requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 office visit (99204), and an ultrasound study of arteries of both arms and legs (93923) provided on August 20, 2019 by the out of network provider.