Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for drugs or medicaments dispensed in the office for home use (D9630) and the periodontal scaling and root planing (D4342) received February 8, 2021 from the out-of-network provider.
You asked the Plan to pay for the dental services (D9630, D4342). You say that the requested services should be covered by the Plan. The Plan denied your request. The Plan says supplemental preventive and supplemental comprehensive dental benefits must be obtained from a provider in the Plan's dental vendor network.
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 when received out-of-network. Therefore, we decided that the Plan
does not have to pay for drugs or medicaments dispensed in the office for home use (D9630) and the periodontal scaling and root planing (D4342) received February 8, 2021 from the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transthoracic echocardiography (93306) provided on February 10, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the diagnostic service. You say that the enrollee was seen for an echocardiography for chest pain. Please approve the authorization and reprocess this claim. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 transthoracic echocardiography (93306) provided on February 10, 2021 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on February 3, 2021.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our Plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services, and cases in which our Plan authorizes use of out-of-network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the ambulance services. 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 ambulance services provided on February 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the enrollee does not need services in the LTACH that are not available in the acute care hospital where the enrollee is currently, safely being cared.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833, L2397) provided on December 30, 2020.
You asked the Plan to pay for a knee orthosis. You say that these items are supported by the medical records. The Plan denied your request. The Plan says the documentation is insufficient to support these items.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. There is not an itemized delivery ticket for these items. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833, L2397) provided on December 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a pulmonary disease genetic testing panel provided on August 5, 2020.
You asked the Plan to pay for the pulmonary disease genetic testing panel. You say that this is medically necessary testing. The Plan denied your request. The Plan says this testing is not covered per Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that lab testing must be ordered by the physician who is treating the enrollee for a specific medical problem and uses the results in the management of this medical problem. The testing provided is genetic testing for pulmonary (lung) diseases. This testing was ordered by a podiatrist. A podiatrist, a doctor who treats diseases of the feet, cannot use the results of this testing in the management of pulmonary disease. As such, we find that the Medicare rules for payment of this testing have not been met.
Therefore, we decided that the Plan does not have to pay for a pulmonary disease genetic testing panel provided on August 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomic testing provided on July 11, 2020.
You asked the Plan to pay for the pharmacogenomic testing. You say that this was medically necessary as shown in the records. The Plan denied your request. The Plan says this was billed incorrectly since the rules say it must be reported as a single code.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a provider that is treating the enrollee for a specific medical issue. The results must be used by this provider to manage the medical issue. In this case, there is no evidence of any clear medical issue for which the ordering provider is treating the enrollee. The only progress note is an unsigned note of a telephone encounter on December 12, 2020, five months after this testing was performed. There is no evidence that the ordering provider will use these results in
management of any medical condition. Therefore, we decided that the Plan does not have to pay for the pharmacogenomic testing provided on July 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the charges for the oncology visit provided on January 31, 2020 and the podiatry visit provided on June 8, 2020.
You asked the Plan to waive the charges for the specialist visits. You say that you feel that these claims were paid inconsistently and incorrectly. The Plan denied your request. The Plan says it was found that the February 2021 visit should be paid in full. However, thee $45 copayments for the other two visits at issue is correct as these were specialist providers.
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 $45 copayment for services in a specialist office and podiatry visits.
You have been asked to pay a $45 copayment for each of the specialist visits. 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 charges for the oncology visit provided on January 31, 2020 and the podiatry visit provided on June 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical trays and miscellaneous surgical supplies used during a covered injection procedure on March 4, 2021, billed with codes A4550 and A4649.
You asked the Plan to pay for the surgical trays and other supplies. You say that these services are all payable in the ASC setting. The Plan denied your request. The Plan says these items are not payable.
The Plan must follow Medicare rules. Medicare rules say that payment for the ASC procedure includes payment for all medical and surgical supplies not granted pass-through status. We looked at the file and Medicare rules. The items described by A4550 and A4649 are not on pass-through status. As such, payment for the procedure includes payment for these supplies. No additional payment can be made for these items. Based on this information, we decided that Medicare rules for coverage of the surgical trays and other supplies have not been met. Therefore, we decided that the Plan does not have to pay for the surgical trays and miscellaneous surgical supplies used during a covered injection procedure on March 4, 2021, billed with codes A4550 and A4649.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified removable prosthodontic procedure (D5899) provided on February 3, 2020.

You asked the Plan to pay for the unspecified prosthodontic procedure. You say that these services are supposed to be covered by your Plan and you do not have the money to afford these services. The Plan denied your request. The Plan says they agreed that some of the services should be covered, however an unspecified removable prosthodontic procedure is not covered by your 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 pay for the unspecified removable prosthodontic procedure (D5899) provided on February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 2, 2021.
You asked the Plan to pay for the laboratory services. 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. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that your practice was one of the only offices in the area at the time of service. The Plan denied your request. The Plan says 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 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 office visit provided on December 2, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for inpatient hospital stays on September 10 to October 2, 2020, and on October 7 to October 16, 2020.
You asked the Plan to waive the copayments for inpatient hospital stays. You say that the hospital did not thoroughly examine whether you were fully recovered to be discharged. The Plan denied your request. The Plan says the correct copayments were 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 $100 copayment for each day of days 1 to 7 for Medicare-covered hospital stays.
You have been asked to pay 2 payments of $700, or a $100 copayment for each day of days 1-7 for each of 2 admissions for inpatient hospital stays. Inpatient hospital stays fall within the "Inpatient hospital 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 have to waive the copayments for inpatient hospital stays on September 10 to October 2, 2020, and on October 7 to October 16, 2020.
Your complaint about the second inpatient hospital stay having been potentially unnecessary 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 14, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you were told by sales you can go to any doctor or hospital. The Plan denied your request. The Plan says 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 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 office visit provided on January 14, 2021 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 individual psychotherapy (90834) provided on January 21, 2021 by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says non-emergent services with non-contracted providers require prior authorization before services being rendered.
The Plan must follow Medicare rules. The contract with the plan says that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare.
As a member of the Plan you can receive your care from either a network provider or an out-of-network provider. Page 124 of the Evidence of Coverage specifically says that prior authorization may be required for outpatient mental health 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 individual psychotherapy (90834) provided on January 21, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more than the benefit allowance for eyeglasses provided on March 12, 2021.
You asked the Plan to pay more than the benefit allowance for the eyeglasses. You say that you only spent $160 for the eyeglasses. The Plan denied your request. The Plan says that the Plan paid the $200 vision allowance amount, and you exceeded the allowance amount, and you are responsible for all costs over and above the allowance amount.
Medicare generally does not cover eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan paid the correct vision allowance of $200, and you are responsible for all costs over and above the allowance amount. Therefore, we decided that the Plan does not have to pay more than the benefit allowance for eyeglasses provided on March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on March 15, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan denied your request. The Plan says 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 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 drug testing provided on March 15, 2021 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on January 31, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted
medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code G0483 is not supported in the record. Specifically, the claim was submitted with a laboratory place of service code, but the record indicates that the member's face-to-face service was rendered in an office setting. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on January 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 12, 2021.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are 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 February 12, 2021. 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 the ambulance services provided on February 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lab services you had on February 9, 2021.

You asked the Plan to waive the copayment for the lab services. You say that you think this copayment should be waived because it was part of your annual physical exam, even though it was done at a separate time. The Plan denied your request. The Plan says you were charged this copayment 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 $10 copayment for laboratory tests that are not fecal immunochemical (FIT) tests.

You have been asked to pay a $10 copayment for the lab services. Although these lab services may have been ordered as a result of your annual physical, lab services are not considered part of the annual physical. Your Evidence of Coverage clearly states that the annual physical exam includes body system examinations, measurement and recording of vital signs, a complete prescription medication review, and a review of recent hospitalizations. It does not include lab services. 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 lab services you had on February 9, 2021.