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

We decided that the Plan does not have to pay for the medical services provided to the enrollee on July 22, 2019.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization and the enrollee's plan physician did not order this service.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee on July 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 11, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the
documentation submitted did not include a valid physician order/lab requisition or medical records; therefore
the billed code cannot be verified.
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 drug testing services have not been met. Therefore, we decided that the Plan
does not have to pay for the drug testing services provided on September 11, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on August 1, 2019.
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 that the services are not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the
laboratory services is considered approved by the plan. Therefore, we decided that the Plan has to pay for the
laboratory services provided on August 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the consultation, including oral evaluation (D9310), and the surgical extraction (D7250) provided on December 6, 2019 by an out of network provider.
You asked the Plan to reimburse you for the dental services. You say that you went to an in network dental provider and were recommended you have a tooth pulled. You say that the in network dental provider referred to this provider. You say that you were initially advised that the services would be covered. You say that the signage in the provider's office was deceiving and you should be reimbursed $495. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says that they confirmed with your dental plan that there was no referral on file for the services you received.
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 consultation and extraction are not covered when you receive them out of network. Additionally, the Plan confirmed with your dental plan that there was no referral on file for the services that you received. Therefore, we decided that the Plan does not have to reimburse you for the consultation, including oral evaluation (D9310), and the surgical extraction (D7250) provided on December 6, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 5, 2019 by an out of network (OON) provider. You asked the Plan to pay for office visit and ultrasound exam. You say that the provider said that they accept this Plan. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and prior authorization was not 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 the medical services provided on November 5, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the physician visit or the cardiac catheterization procedure from June 13, 2019 to June 14, 2019.
You asked the Plan to reduce the coinsurance for the physician visit and the cardiac catheterization procedure. You say that you should be charged the in-network rate. 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 40% coinsurance for out-of-network provider and professional services and 40% coinsurance for out-of-network surgery services at an outpatient hospital. You have been asked to pay a total of $545.32 for the physician visit and the cardiac catheterization procedure. The physician visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The cardiac catheterization procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" category. The record shows the provider is out-of-network. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
June 13, 2019
Physician visit
$172.44
40%
$68.98
June 14, 2019
Cardiac catheterization
$1,190.88
40%
$476.34
Total
$545.32
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 reduce the coinsurance for the physician visit or the cardiac catheterization procedure from June 13, 2019 to June 14, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided by an OON dentist on March 31, 2016.
You asked the Plan to pay for the resin-based composite. You say that you live on social security and have no other income and the amount you get is very little and insufficient. The Plan denied your request. The Plan says the provider who performed this service is not in the Plan's network. The Plan also says that you must use network providers to receive dental services.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the resin-based composite provided by an OON dentist on March 31, 2016.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the port flush provided on January 2, 2020.
You asked the Plan to reduce the copayment for the port flush. You say that you have only had to pay $24.60
previously for this service. 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 $340
copayment for Medicare-covered surgical and non-surgical services in an in-network outpatient department of
a hospital or in an ambulatory surgical center. For this date of service, you have been asked to pay the allowed
amount of the claim because this amount is less than the $340 copayment for the port flush.
You have been asked to pay a $49.19 copayment for the port flush. The port flush falls within the "Outpatient
Hospital 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 reduce the copayment for the port flush
provided on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 23, 2019.

You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.

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 drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308) provided on November 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for nursing facility care. You say that this service should be covered. The Plan denied your request. The Plan says this service 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 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 nursing facility care (99308) provided on November 16, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgical services rendered to the enrollee on September 19, 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 services were rendered without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that prior authorization is required for certain services at an in-network outpatient hospital facility or ambulatory surgical center. The file shows that the services were rendered at an in-network ambulatory surgical center without prior authorization, as required by the Plan contract. 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 outpatient surgical services rendered to the enrollee on September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 19, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 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 physician's 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 physician's services provided on November 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 7, 2019 by an out of network provider
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The Plan denied your request. The Plan says you did not request prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 7, 2019 by an out of network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroilaic joint injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of adequate conservative treatment failure, such as activity modification, physical therapy, and NSAIDs.
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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found there has been no trial of physical therapy. At this point, physical therapy has not been documented to be contraindicated. Therefore, this request is not medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroilaic joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cosyntropin infusion services 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 adrenal lab results were not submitted with this request.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee is given a diagnosis of primary adrenal insufficiency. The only supporting documentation was a single set of labs drawn at 10 AM on 8/8/2019 in which cortisol was 7.42, DHEA was 8.6 and TSH was 0.18. No other history or physical examination was submitted. This lab data is over 7 months old. Based on the submitted documentation, the Cosyntropin infusion services are not 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve Cosyntropin infusion services for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One
You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says the enrollee has not had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc.
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 physician reviewer found that the enrollee has primary osteoarthritis of the right knee. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drugs. The documentation does not support that Orthovisc and Monovisc would likely be less effective, or would likely have adverse effects for the enrollee in this case. 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
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal MRI provided on November 11, 2019.
You asked the Plan to pay for the spinal MRI. You say that you wanted to be able to be treated for your pain
without having to return to the service area and you need an MRI in order to get epidural injections. The Plan
denied your request. The Plan says there was no reason you could not return home to get treated for your pain.
Your plan does not cover treatment of pain while out of the service area if it is possible for you to return to get
treatment.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.
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 spinal MRI. Our reviewer says that the
MRI provided is not considered urgently need out of area care. Our physician reviewer found the enrollee was
evaluated in an Emergency Department on 10/27/19 for bilateral hip pain. A CT scan was obtained, which
demonstrated severe multilevel narrowing of the thecal sac, and moderate and severe foraminal narrowing. It is
documented in an Orthopaedic note dated 11/4/19 that the enrollee had a 3-week history of low back pain. The
treatment options for the enrollee included "living with the condition as it is, activity modification, physical
therapy, chiropractic manipulation, epidural cortisone injections, pain management in the form of medications,
and surgery." An MRI was ordered.
The documentation does not support that imaging was medically reasonable and necessary prior to the enrollee
returning to his service area. The MRI could be reasonably delayed until the spring when the enrollee intended
to return.
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 spinal MRI have not been met. Therefore, we decided that the Plan does not
have to pay for the spinal MRI provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on August 26, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied
your request. The Plan says payment of this service is bundled into other services.
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 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code
95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not
a separately reportable procedure and is included in the other interoperative neuromonitoring procedures.
Based on this information, we decided that Medicare rules for coverage of train of four testing have not been
met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on
August 26, 2019.