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

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) provided by out of network (OON) provider on December 10, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were provided by an out of network provider at a non-participating facility, without 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 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 domiciliary or rest home visit for the evaluation and management of an established patient (99336) provided by the out of network (OON) provider on December 10, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the pathology services rendered to you on November 12, 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 that the services were billed by an independent laboratory. 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. You were referred for these services by a contract provider. The file does not show that the Plan provided notice that these services would not be covered. Under Medicare rules, this means these services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the pathology services rendered to you on November 12, 2019. If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 2, 2019 to the enrollee by an out of network (OON) provider.
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 by an out-of-network provider without 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 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 October 2, 2019 tothe enrollee by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 18, 2019 to the enrollee by an out of network (OON) provider.
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 by an out-of-network provider without 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 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 July 18, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visual field examination provided on November 5, 2019. You asked the Plan to waive the copayment for the visual field examination. You say that this was previously covered by the office copayment. You say that you shouldn't have an additional copayment for the diagnostic test. 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 $10 per day for Medicare-covered tests. You have been asked to pay a $10 copayment for the visual field examination. The visual field examination falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 visual field examination provided on November 5, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 28, 2019 to August 30, 2019. You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically necessary. The Plan denied your request. The Plan says that an inpatient level of care was not necessary. The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the records show that the enrollee presented to the emergency room with sharp intermittent chest pain that radiated to left arm and elevated blood pressure. She stayed in the hospital for 2 days for evaluation and diagnostic testing. The record shows that at the time of inpatient admission, the admitting physician reasonably expected that the patient's necessary hospital care would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from August 28, 2019 to August 30, 2019. If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on December 3, 2019. You asked the Plan to pay for the chiropractic manipulative treatment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that this service was provided by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service 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 this service. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on December 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on November 27, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 for the drug testing rendered to the enrollee on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 28, 2019 by an out of network (OON) provider. You asked the Plan to pay for an office visit. You say that this visit was due to Alzheimer's disease. You say that these services were 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on October 28, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible charges for the services you received on October 1, 2019. You asked the Plan to waive the deductible. The Plan denied your request. The Plan says you must meet the deductible. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $183 deductible for covered Part B services from both in-network and out-of-network providers. Review of the file shows that you were provided in-network services on October 1, 2019. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $183 deductible for covered Part B services from both in-network and out-of-network providers. This cost sharing is a contractual obligation that had not been met at the time the services was received on October 1, 2019. Therefore, we decided that the Plan does not have to waive the deductible charges for the services you received on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the lumbar spine (72100) and the x-ray exam of the cervical spine (72040) provided on October 14, 2019. You asked the Plan to pay for these services. You say that you were advised by the health plan that you would be responsible for the applicable copayment for the office visit and the x-ray services. The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy. The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the x-ray exam of the lumbar spine (72100) and the x-ray exam of the cervical spine (72040) provided on October 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the hernia repair surgery provided on November 6, 2019. You asked the Plan to reduce the copayment for the hernia repair surgery. You say that you were told you would be charged the ambulatory surgical center copayment. 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 $400 copayment for Medicare-covered in-network outpatient hospital surgery services. You have been asked to pay a $400 copayment for the hernia repair surgery. The hernia repair surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital. This means that 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 hernia repair surgery provided on November 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmology services (92012) provided October 16, 2019.
You asked the Plan to waive the copayment for the ophthalmology services. You say that you made an appointment for a pressure check only but after the appointment you were billed $30 copayment and you feel that there should be no copayment. The Plan denied your request. The Plan says the claim processed correctly and the correct copayment was applied.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay $30 copayment for physician services for physician services to diagnose and treat diseases and conditions of the eye. You have been asked to pay $30 copayment for physician services for physician services to diagnose and treat diseases and conditions of the eye. for the ophthalmology services. the ophthalmology services fall within the Vision 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 copayment for ophthalmology services (92012) provided October 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 11, 2019 by an out of network (OON) provider. You asked the Plan to pay for nursing facility care (90833, 99310, 99356 and G8427). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the services received were not authorized and therefore not payable. 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 October 11, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on September 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were medically necessary. You say that these services were provided at a care center. 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 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 skilled nursing services provided on September 4, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on October 1, 2019 by an out of network (OON) provider. You asked the Plan to pay for genetic testing. You say that you are requesting the initial denial on the claim to be overturned. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also 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 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 genetic testing provided on October 1, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing rendered to the enrollee on September 26, 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 testing is not covered.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479. The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 for the Guardant360 testing rendered to the enrollee on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit you had on November 11, 2019.
You asked the Plan to pay for the visit. You say that you did not know this was another annual wellness visit. The Plan denied your request. The Plan says this is only covered once per year.
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 $0 copayment for an annual wellness visit once every 12 months. Review of the file shows that you had an annual wellness visit on November 11, 2019. The records also show that you had an annual wellness visit on July 22, 2019. The plan paid for the first wellness visit. This means that the requested visit exceeds the benefit limit and is not covered. Therefore, we decided that the Plan does not have to pay for the annual wellness visit you had on November 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planings of four or more teeth per quadrant (D4341) of the lower right and upper left quadrants, two core buildups, including any pins when required (D2950), and two crowns (D2740).
You asked the Plan to pre-approve the periodontal scaling and root planing (D4341) of the lower right and upper left quadrants, core buildups, and crowns. The Plan denied your request. The Plan says that core buildup and crown are not included as covered benefits. The Plan also says that the received x-rays show that the enrollee does not have at least four teeth in the lower right quadrant of his mouth.
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. The Plan covers the periodontal scaling and root planing (D4341) of the lower right and upper left quadrants when the services are medically necessary and reasonable.
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 periodontal scaling and root planings (D4341) of the lower right and upper left quadrants. Our reviewer says that the periodontal scaling and root planing of the lower right and upper left quadrants is not medically necessary. Our physician reviewer found the maxillary left quadrants and mandibular right quadrants each have three teeth present. Our reviewer also found that coverage for periodontal scaling and root planing using code D4341 requires four or more teeth in the quadrant. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the periodontal scaling and root planing (D4341) of the lower right and upper left quadrants have not been met. Though the Plan offers a dental benefit in excess of Medicare coverage, core buildups, including any pins when required (D2950) and crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planings of four or more teeth per quadrant (D4341) of the lower right and upper left quadrants, two core buildups, including any pins when required (D2950), and two crowns (D2740).