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

We decided that the Plan does not have to pay for assisted living services provided on November 15, 2019 by an out of network (OON) provider.You asked the Plan to pay for assisted living services. You say that the member is in an assisted living facility; therefore, the doctor is not responsible to get authorization. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring facilityis 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 assisted living services provided on November 15, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found.
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 31, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care on January 16, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were only in the
emergency room and then admitted to a regular hospital room. The Plan denied your request. The Plan says the
claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received inpatient hospital care on January 16, 2020. You are asked to pay a
$300 copayment for the inpatient hospital care. 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 inpatient
hospital care on January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on September 3, 2019.
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 Current Procedural Terminology (CPT) code 80307 and Healthcare Common Procedure Coding System (HCPCS) G0483 remain not supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on September 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) and topical application of fluoride varnish (D1206) provided on October 29, 2019. You asked the Plan to pay for the dental service. You say that you understand the maximum allowance is met and that you must pay the balance however you are asking for reconsideration. You have been contributing monthly to the plan and cannot afford any more. The Plan denied your request. The Plan says the annual maximum benefit has been exhausted. Fluoride varnish is not listed as a covered service. 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 records show that the plan has paid the annual maximum. 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 periodontal scaling and root planing (D4341) and topical application of fluoride varnish (D1206) provided on October 29, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided September
12, 2019 to September 17, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF
services. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of
coverage were not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 pay for the SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily
basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled
nursing facility setting.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for skilled nursing facility (SNF) services provided September 12, 2019 to September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the sacroiliac joint injection, medical supplies and Part B drugs provided on October 10, 2019. You asked the Plan to waive the cost share for the sacroiliac joint injection, medical supplies and Part B drugs. You say that you were not informed of the copayment. You say that you cannot afford this bill. The Plan denied your request. The Plan says the cost share 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 $395 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges, 20% coinsurance for each Medicare-covered medical supply and 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay a total of $399.74 for the sacroiliac joint injection, medical supplies and Part B drugs. The sacroiliac joint injection falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The medical supplies fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The Part B drugs fall 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 cost share for the sacroiliac joint injection, medical supplies and Part B drugs provided on October 10, 2019.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to reduce the cost for the cataract removal. We decided that the Plan does not have to waive the cost for the phenylephrine solution.
You asked the Plan to waive the cost for the cataract removal and phenylephrine solution. You say that you were informed that insurance would cover all of the cost. The Plan says that the coinsurance applied correctly.
We decided that the Plan has to reduce the cost for the cataract removal.
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 for surgery services at an in-network ambulatory surgical center. The cataract removal is considered a surgical procedure.
The Plan says that you must pay 20% coinsurance for the cataract removal. Based on the Plan contract, however, you cannot be asked to pay more than a $150 copayment. Therefore, we decided that the Plan has to reduce the cost for the cataract removal from $187.40 to $150.
We also decided that the Plan does not have to waive the cost for the phenylephrine solution.
Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B covered drugs from an in-network provider. The allowed amount of the phenylephrine solution is $449.40 (20% x $449.40 = $89.88). Therefore, we decided that the Plan does not have to waive the cost for phenylephrine solution.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an EGD provided on November 27, 2019.
You asked the Plan to waive the coinsurance for an EGD. You say that you disagree with the additional 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 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received an EGD on November 27, 2019. An EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay your share of the cost-sharing charges. The allowed amount is $1,702.89 and 20% of that is $340.58. You have been asked to pay the total coinsurance amount of $340.58 for an EGD. An EGD 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 coinsurance for an EGD provided on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on November 12, 2019.
You asked the Plan to pay for the assembly and operation of a pump with oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on November 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 21, 2019 by an out of network (OON) provider.You asked the Plan to pay for diagnostic tests. You say that you cannot always obtain authorization, and you cannot deny service because you have a contract with the nursing facility.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 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 December 21, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray provided on August 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an x-ray. You say that you are the member's primary care physician. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found. 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 an x-ray provided on August 28, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on December 2, 2019 by an out of network (OON) provider. You asked the Plan to pay for wound care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring facility is out-of-network. The Plan says that 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 wound care provided on December 2, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued out-of-network tertiary level of care.You asked the Plan to pre-approvecontinued out-of-network tertiary level of care. You say that the continued out-of-network tertiary level of care is medically necessary.The Plan denied your request. The Plan says the continued out-of-network tertiary level of care is not medically necessary, and the enrollee can safely transition to a network, non-tertiary hematologist/oncologist.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for 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 pre-approve continued out-of-network tertiary level of care. Our reviewer says that the continued out-of-network tertiary level of care is not medically necessary, and the enrollee can safely transition to a network, non-tertiary hematologist/oncologist. Our physician reviewer found the enrollee was diagnosed with Philadelphia positive acute lymphoblastic leukemia since March 2016. He was induced with hyper-CMAD and dasatinib and responded well and achieved a CMR. He completed his maintenance therapy in November 2018 and maintained on dasatinib since then. Based on the documentation provided, the enrollee is not currently receiving any active treatment and/or medical management of his condition that makes it medically necessary for this enrollee to continue care with the out-of-network tertiary level hematologist/oncologist provider as requested. There is nothing unique about this enrollee's condition that would make it medically necessary for him to continue care with the out-of-network provider. The Plan has shown that they have in-network hematology/oncology specialists available who havethe qualifications and expertise necessary to meet the current medical Standards of Care required for treatment of the enrollee's condition. The enrollee's medical management and/or follow-up care can be safely transitioned to an in-network hematology/oncology specialist at this time. It is not medically necessary for the enrollee to continue treatment with a tertiary level hematology/oncology specialist for the requested follow-up care and blood work and the enrollee can safely transition to an in-networkhematology/oncology specialist.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued out-of-network tertiary level of care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued out-of-network tertiary level of care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on December 29, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that you were informed to get lab work before your annual physical. You say that you aren't supposed to have a copayment. 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 for Medicare-covered laboratory tests. You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall 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 laboratory services provided on December 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a sigmoidoscopy provided on August 20, 2019.
You asked the Plan to waive the copayment for a sigmoidoscopy. You say that you feel that you should only owe a $60 copayment. 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 $300 copayment per visit for outpatient surgery performed in an ambulatory surgical center. You have been asked to pay a $300 copayment for a sigmoidoscopy. A sigmoidoscopy 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 a sigmoidoscopy provided on August 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for treatment of root canal obstruction; non-surgical access (D3331) provided on October 22, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for treatment of root canal obstruction; non-surgical access (D3331) provided on October 22, 2019.