Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 10, 2021 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you were told by a representative that these charges would be paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the rendering physician is out-of-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided on February 10, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (CPT 33249) provided to the enrollee on June 19, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the non-participating provider did not bill any of the allowable diagnoses that will allow this service to process for payment.
The Plan must follow Medicare rules. Medicare rules say that services must be reported with the appropriate diagnosis code. 
The file does not show that an appropriate diagnosis code was billed in this case. 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 physician services (CPT 33249) provided to the enrollee on June 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on March 23, 2021.

You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you are allowed two exams per year and one x-ray per calendar year. The Plan denied your request. The Plan says your benefits for these services have been satisfied and the frequency limitation has been exceeded.

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, comprehensive oral evaluation is limited to one procedure code every three years, and full mouth or panoramic x-rays are limited to one procedure code every five years. The record shows that you received a comprehensive oral evaluation and complete series of intraoral x-rays on August 3, 2020 and your comprehensive oral evaluation and full mouth or panoramic x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam image capture (D0367) provided on April 20, 2021.

You asked the Plan to pay for the dental imaging. You say that your provider said this service was necessary, and you did not know that it would not be covered. The Plan denied your request. The Plan says this service is not covered by your dental benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone beam image capture (D0367) provided on April 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 2, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 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 services provided by an out-of-network provider on March 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 28, 2020.
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 claims were billed incorrectly.
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 a laboratory setting; 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 drug testing rendered on October 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the closure of a tear duct opening provided
on October 1, 2020.

You asked the Plan to waive the copayment for the closure of a tear duct opening. You say that you feel that
the procedure should not be considered a surgical procedure as it took less than 30 seconds. 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 $400
copayment for outpatient surgery, including services provided at hospital outpatient facilities.

You received the closure of a tear duct opening at an outpatient hospital facility on October 1, 2020. The
closure of a tear duct opening is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $400 copayment. 

You have been asked to pay a $400 copayment for the closure of a tear duct opening. The closure of a tear duct opening 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 closure of a tear duct opening provided on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit and coinsurance for an injection provided by a participating provider on January 14, 2021.

You asked the Plan to waive the copayment for an office visit and coinsurance for an injection. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct charges have been 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 $50 copayment for physician/practitioner services/specialist and a 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a $50 copayment for an office visit. You have also been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $11. The amount you are being asked to pay for an injection is $2.20 ($11 x 20% = $2.20). The total amount you are being asked to pay is $52.20 ($50 + $2.20 = $52.20). The correct charges have been applied to the services that were provided. An office visit falls within the physician/practitioner services/specialist benefit category and an injection falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit and coinsurance for an injection provided by a participating provider on January 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.

You asked the Plan to pre-approve the drug. You say that there is evidence that immunotherapy may have some benefits in the CDK 12 mutant population. The Plan denied your request. The Plan says this is not medically necessary.

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 drug. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found that in this case, the record indicates that the enrollee has metastatic prostate cancer. The Medicare approved cancer compendia do not contain supportive citations for the requested drug in this clinical scenario. No literature from Medicare approved cancer journals was submitted for review. The medical necessity and reasonableness of the requested service as defined by Medicare rules is not established by the provided records.

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and the additional
periapical x-ray (D0230) provided on December 31, 2020.

You asked the Plan to pay for the dental services. You say that the provider would not perform your cleaning
without taking the x-rays. The Plan denied your request. The Plan says periapical x-rays are not listed as
covered 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided on December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on February 22, 2021.

You asked the Plan to pay for the eye refraction. You say that this visit was a follow-up after your cataract surgery. The Plan denied your request. The Plan says these services were billed with routine diagnoses and not with cataract-related codes. Based on the information submitted in the claim, this was a routine eye refraction. Routine vision services will only be covered when they are received from a provider in the specified routine vision network.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are received from a provider in the Plan's routine vision network. 

We looked at the file and the Plan's rules. The eye refraction was billed with routine diagnoses and was provided outside of the Plan's routine vision network. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the cleaning (D1110), periodic oral exam (D0120), bitewing x-rays (D0274) and two crowns (D2740) provided on January 12, 2021, by an out-of-network provider.

You asked the Plan to pay an additional amount for the out-of-network dental care. You say that you expected any and all dental services to be covered and paid by the Plan up to the $1,000 annual maximum. The Plan denied your request. The Plan says all covered services are subject to the applicable coinsurance for the provided service and then payable up to a maximum benefit of $1,000 per calendar year. Records indicate that you did not reach out to the Plan to verify benefits or provider eligibility. The Plan paid the applicable 50% coinsurance on the maximum allowed fee for the covered services, which were rendered by an out-of-network provider. In addition, crowns are 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. Your contract with the Plan clearly says that you must pay 50% coinsurance for covered dental cleanings, exams and x-rays that are received from an out-of-network provider. In addition, benefits received out-of-network are subject to any in-network benefit maximums, limitations and/or exclusions, and you may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider.

Though the Plan offers a dental benefit in excess of Medicare coverage, dental crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two crowns (D2740) provided on January 12, 2021, by an out-of-network provider.

The out-of-network provider billed the Plan a total of $178 for the cleaning, exam and x-rays provided on January 12, 2021. The Plan's total allowed amount for these three services is $89. Network dentists have agreed to provide services at this rate and not bill you for any amount greater than this rate. However, out-of-network dentists do not have this agreement and are allowed to bill you for the difference between their charges and the Plan's rate for the covered services. ($178 - $89 = $89). In addition, you are responsible for 50% coinsurance of the Plan's maximum fee for covered dental cleanings, exams and x-rays that are received out-of-network. ($89 x 50% coinsurance = $44.50). You have been asked to pay $133.50 for these three services. ($89 out-of-network charges in excess of the Plans rate + $44.50 coinsurance = $133.50). 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 pay an additional amount for the cleaning (D1110), periodic oral exam (D0120) and bitewing x-rays (D0274) provided on January 12, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 31, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that the visit should be fully covered and you disagree with the charges. 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 $35 copayment for specialist visits.
You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 17, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 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 services provided by an out-of-network provider on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on December 3, 2020.
You asked the Plan to pay for the laboratory test. You say that the code used on the claim accurately represents the procedure performed. You say that you are requesting the Plan to process and pay the claim per Medicare guidelines. The Plan denied your request. The Plan says the non-urgent service is not authorized because the provider is a non-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 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 laboratory test provided by an out-of-network provider on December 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied
your request. The Plan says the service is not medically necessary or reasonable.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the patient does require physical and occupational therapy but there is no documented
need for an intensive rehabilitation program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for COVID-19 testing (U0003) provided on December 21, 2020.

You asked the Plan to pay for COVID-19 testing. You say that this should be covered as an in-network service. The Plan denied your request. The Plan says this must be billed through the SNF.

The Plan must follow Medicare rules. Medicare rules say that laboratory tests performed for a SNF's Medicare inpatients covered under Part A are included in the Prospective Payment System (PPS) SNF payment. 

We looked at the file and Medicare rules. The record shows that the laboratory test at issue was provided while the enrollee was in a Part A SNF stay. Payment for this service is included in the PPS SNF payment. Based on this information, we decided that Medicare rules for coverage of COVID-19 testing have not been met.

Therefore, we decided that the Plan does not have to pay for COVID-19 testing (U0003) provided on December 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator, electronic shock unit (E0745) provided October 4, 2020.
You asked the Plan to pay for the electronic shock unit. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is evidence of misrepresented services.
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 physician order, proof of delivery,or a delivery ticket for the supplies provided in this case. 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 the neuromuscular stimulator, electronic shock unit (E0745) provided October 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair (E0245) provided on February 11, 2021.
You asked the Plan to pay for a shower chair. You say that you are not able to stand in the shower due to a recent stroke. The Plan denied your request. The Plan says rules for a shower chair have not been met.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a shower chair (E0245) provided on February 11, 2021.