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

We decided that the Plan does not have to pay for the lab services provided on July 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. The Plan says that neither the referring provider nor the provider of service is a network provider with 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 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 lab services provided on July 30, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on August 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the physician provided medically necessary services in good faith. The Plan denied your request. The Plan says 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 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 services 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 radiology services provided on August 20, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aid services with CPT codes V5010 and V5020 provided on July 1, 2020.You askedthe Plan to pay forthe hearing aid services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says screening services related to hearing aids are covered at 25% coinsurance for out-of-network providers. The Plan says that during your visit on July 1, 2020, three distinct screening services were performed. The Plan says that CPT code V5008 has been reprocessed and paid. The Plan says that the additional services, CPT codes V5010 and V5020, are considered part of service V5008 and are not allowed for additional reimbursement.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan says for hearing aids purchased at an out-of-network provider enrollees pay a 25% coinsurance, then any amount over $1000.We looked at the file and the Plan's rules. The Plan's rules say for hearing aidspurchased at an out-of-network provider, you pay a 25% coinsurance, then any amount over $1000. Any amount over $1000 is considered your responsibility. The file shows that with your 25% coinsurance of $250, the Plan paid the remainder of the $1000 benefit limit for your hearing aids. Anything over this $1000 limit is your responsibility.Therefore, we decided that the Plan does not have to pay forthe hearing aid services with CPT codes V5010 and V5020 provided on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultation - diagnostic service by dentist (D9310).
You asked the Plan to pre-approve consultation - diagnostic service by dentist. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not a covered 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 consultation - diagnostic service by dentist (D9310).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by THE Ambulance on September 23, 2020.You asked the Plan to pay forthe ambulance services. 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 September 23, 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 forthe ambulance services provided by THE Ambulance on September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided.

You asked the Plan to pay for the genetic testing. You say that you would like reconsideration because this testing is medically necessary.The Plan denied your request. The Plan says this service was not billed correctly.

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, the genetic testing, was requested solely for screening purposes. The documentation does not show that the requested pharmacogenomic testing was ordered due to any signs/symptoms of a drug reaction. There is no evidence that the testing was provided for therapeutic decision-making regarding the need for the use of any specific drug.  Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the genetic testing provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 22, 2020, by an out-of-network provider.You asked the Plan to pay forthe medical services. You say that the claim should be paid.The Plan denied your request. The Plan says the services were not authorized by the Plan to be performed by an out-of-networkprovider. The Plan states the services are not considered urgent/emergent in nature.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 forthe medical services provided onJune 22, 2020, by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve physical therapy services to be provided by an OON provider. You say that the services are necessary.The Plan denied your request. The Plan says the services are available in-network. Therefore, coverage criteria has not been met.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

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 physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on July 7, 2020.
You asked the Plan to pay for the first intraoral periapical x-ray. You say that you were told that this work would be covered in full. The Plan denied your request. The Plan says this service is not covered.
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 first intraoral periapical x-ray provided on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assistant surgeon services rendered on June 26, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was billed incorrectly.ThePlan must follow Medicare rules. Medicare rules say that modifier 80, 81 or 82 must also be billed when modifier AS is billed.We looked at the file and Medicare rules. The file shows that the assistant surgeon services were not billed with the required 80 modifier for services performed by a nurse practitioner. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe assistant surgeon services rendered on June 26, 2020
Appeal type: Drugs
Decision: Unfavorable

e decided that the Plan does not have to pre-approveEntyvio for the enrollee.You asked the Plan to pre-approveEntyvio. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that there is no indication there preferred drug would likely be less effective, and/or cause adverse effects for the member.Medicare covers PartB 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 Entyvio. Our reviewer says that Entyvio is not medically reasonable and necessary for the enrollee in this case. The patient has not tried and failed Stelara. There is no documentation provided indicating that Stelara would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meetstep therapy criteria for Stelara.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met.Therefore, we decided that the Plan does not have to pre-approveEntyvio for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Iv tubing extension set and infection control supplies provided on August 8, 2020.You asked the Plan to pay forthe Iv tubing extension set and infection control supplies. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the items billed are not payable.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 codes S1015 and S8301 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the Iv tubing extension set and infection control supplies have not been met.Therefore, we decided that the Plan does not have to pay forthe Iv tubing extension set and infection control supplies provided on August 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on July 24, 2020.You asked the Plan to waive the copayment forthe CT scan. You say that you shouldn't have a higher cost than the Plan. You say that you thought the member always paid less.The Plan denied your request. The Plan says the copayment 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 $150 copayment per visit for all other outpatient diagnostic and therapeutic services and supplies, such as MRA's, MRI's, CT scans, PET scans, and hyperbaric oxygen therapy. You have been asked to pay a $150 copayment for the CT scan. The CT scan falls 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 youagreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe CT scan provided on July 24, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay foremergency department visit for the evaluation and managementof a patient (CPT Code 99284) provided on July 27, 2020.You asked the Plan to pay forthe service. You say that the claim should be paid.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.Based on this information, we decided that Medicare rules for coverage of the service have not been met. CPT code 99284 denied because it was reported with another evaluation and management service, 99285 (Emergency department visit for the evaluation and management of a patient) billed on the same day by the same provider. Per review of both claims, the same diagnosis codes were billed indicating that the additional E/M was for the same problems. Therefore, recommendation for CPT code 99284 is to uphold the original denial.Therefore, we decided that the Plan does not have to pay foremergency department visit for the evaluation and management of a patient (CPT Code 99284) provided on July 27, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay from August 30, 2020, to September 3, 2020.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you feel that the charges should be covered because you accidentally broke your hip.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for days 1-6 for inpatient hospital care. You had an inpatient hospital stay from August 30, 2020, to September 3, 2020. Therefore, you are responsible to pay a $295 copayment for days 1-3 (August 30, 2020, to September 1, 2020). $295 (copayment) x 3 (inpatient days) = $885. You have been asked to pay the total copayment amount of $885 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on yourcontract 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 foran inpatient hospital stay from August 30, 2020, to September 3, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services you received on September 16, 2019.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the 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 $35 copayment for each specialist visit. Review of the file shows that you had a specialist visit on September 16, 2019. You have been asked to pay a $35 copayment for the visit. The visit falls within the specialist 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 specialist services you received on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvemedial branch blocks for the enrollee.You asked the Planto pre-approvethe blocks. You say that this is medically necessary, as the enrollee will never be a good surgical candidate.The Plandenied your request. The Plansaysthis is not covered in the presence of radicular symptoms.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 blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has multiple probable pain generators. Therefore, the criteria of the LCD are not met and the request is deemed 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 blocks have not been met.Therefore, we decided that the Plandoes not haveto pre-approvemedial branch blocks for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe PET scan provided on December 18, 2019.You asked the Plan to pay forthe PET scan. The Plan denied your request. The Plan says this is a duplicate claim.The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The records show that the services inquestion were billed on a duplicate claim to one previously processed and paid by the Plan. Duplicate claims are not payable. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met.Therefore, we decidedthat the Plan does not have to pay forthe PET scan provided on December 18, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, prophylaxis, and resin-based composite provided from June 18, 2020, to July 15, 2020, by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, intraoral periapical x-rays, prophylaxis, and resin-based composite. You say that you have been seeing this provider since 2014, and were unaware that this provider is OON. The Plan denied your request. The Plan says the treating provider is not a part of the Plan's network. The Plan also says that no benefits are available for procedures performed by OON providers.
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 OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, prophylaxis, and resin-based composite provided from June 18, 2020, to July 15, 2020, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric services provided from May 9,
2020, to May 20, 2020.
You asked the Plan to pay for the inpatient psychiatric services. You say that you are unaware why this claim
has not been paid by the Plan and would like it reprocessed and approved for payment. The Plan denied your
request. The Plan says you have exhausted the lifetime inpatient psychiatric hospital benefit.
The Plan must follow Medicare rules. The rules say that there is a lifetime maximum of 190 days on inpatient
psychiatric hospital services.
We looked at the file and Medicare rules. The file indicates that you have already received 190 days of
inpatient psychiatric hospital services and have thereby exhausted your benefit for coverage of inpatient
psychiatric services. Based on this information, we decided that Medicare rules for coverage of the inpatient
psychiatric services have not been met. Therefore, we decided that the Plan does not have to pay for the
inpatient psychiatric services provided from May 9, 2020, to May 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L3000).
You asked the Plan to pay for foot orthotics. You say that you have diabetes and therefore the orthotics should be covered. The Plan denied your request. The Plan says the record shows the orthotics were ordered for arthritis. There is no record of diabetic foot disease.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3000).