Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on September 25, 2018
by an out of network provider.
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when
provided by an out of network provider.
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 your PCP's health network providers only in cases
involving emergencies, out of area urgent care and pre-approved care.
While the rendering provider in this case is a network provider with the Plan, the provider is not affiliated with
your PCP's health network. The Plan has providers in your PCP's health network 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 psychotherapy services provided on September 25, 2018 by an out of network provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the Methylprednisolone Acetate injection (J1040) provided on October 08,2019.You asked the Plan to pay for these services. You say that this was medically necessary.The Plan denied your request. The Plan says that that this is not covered under Part B.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 physician. Physician is 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 is considered approved by the plan.Therefore, we decided that the Plan has to pay for the Methylprednisolone Acetate injection (J1040) provided on October 08, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient stay provided from September 19, 2019 to September 26, 2019.
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you were inpatient longer than you needed to be. You say you would like the copayment reduced. 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 $295 copayment for each day for days 1 to 6 for Medicare-covered hospital care and a $0 copayment for additional Medicare-covered days. You have been asked to pay a $295 copayment for each day of the inpatient hospital stay. ($295 x 6 = $1,770). The 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 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 inpatient stay provided from September 19, 2019 to September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, electronic connection, a harness for expandable controller and seat lift for the enrollee.
You asked the Plan to pre-approve these services. You say that these items would enable the enrollee to have freedom and move in a direction of a normal and less painful life. The Plan denied your request. The Plan says that there is not a medical need to control these power options through the joystick.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules also say that a power seat elevation feature is non-covered because it is not primarily medical in nature. 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 an expandable controller, electronic connection and a harness for expandable controller. Our reviewer says that an expandable controller, electronic connection and harness for expandable controller are not medically reasonable and necessary for the enrollee. The documentation notes that the plan has approved a Group 3 power wheelchair with power tilt, power recline and power elevating leg rests. The patient does not require the E2311 controller as the patient's upper limb strength is sufficient for the patient to operate the controls with their own included power options already included in the allowance for these options. There is not a need to control the power options with a joystick, sip
and puff or other non-proportional device, or to operate three or more actuators through the drive control. The patient does not require a separate display, an attendant control and other electronic devices. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these items. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve an expandable controller, electronic connection, a harness for expandable controller and seat lift for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided June 10, 2019 to June 12, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that you respectfully request that the plan reconsider its denial decision and provide authorization and payment for inpatient services.The Plan denied your request. The Plan says the rationale for this determination is not medically 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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the patient presented to the emergency department (ED) on June 10, 2019 with syncope and hypoglycemia. She initially had an unresponsive episode lasting 30 seconds.The review has determined that the enrollee was stable and appropriate for observation level of care services after the ED evaluation on June 10, 2019. Inpatient hospital services June 10, 2019 to June 12, 2019 were not medically necessary and reasonable. On June 11, 2019, it is documented that the enrollee was stable for discharge once her blood sugar was stabilized. The enrollee had no further episodes of hypoglycemia while in the hospital. It was not reasonable for the admitting physician to expect that the enrollee's necessary medical 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 not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided June 10, 2019 to June 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit with a specialist (99213) provided on June 27, 2019 by the out of network provider.
You asked the Plan to pay for an office visit. You say that the rendering provider has been your physician for 15 years and you were unaware that the provider was not participating in your (HMO) plan. You are asking the plan to review and reconsider payment of the denied claim. The Plan denied your request. The Plan says as you are a part of the plan, you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when the member is out of the area), out-of-area dialysis services and cases in which the plan authorizes use of out-of-network providers.
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 with a specialist (99213) provided on June 27, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse a coinsurance for office visits (99213, 99204), and osteopathic manipulative treatments (OMTs) (98929, 98928) provided on September 18, 2019 and on October 2, 2019.You asked the Plan to reimburse a coinsurance for office visits and osteopathic manipulative treatments. You say that you feel 30% of total charges should be reimbursed because the provider doesn't accept the Medicare allowance.The Plan denied your request. The Plan says out-of-network provider services have a 30% coinsurance. The Plan also says that this is a Point of Service (POS) benefit. The POS benefit for out-of-network covered services has a 30% coinsurance.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 30% coinsurance for out-of-network provider services. You have been asked to pay a 30% coinsurance for office visits and osteopathic manipulative treatments. These services fall within the out-of-network provider services benefit category. As per your Explanation of Benefits, you have a yearly $3000.00 Point of Service (POS) benefit. You are responsible to pay a 30% coinsurance for out-of-network services rendered.For September 18, 2019 the Medicare allowable amount was $105.00. The Plan paid 70% or$73.50 leaving you a 30% amount of $31.50. For October 2, 2019 the Medicare allowable amount was $77.85. The Plan paid 70% or$54.49 leaving you a 30% amount of $23.36.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 reimburse a coinsurance for office visits (99213, 99204), and osteopathic manipulative treatments (OMTs) (98929, 98928) provided on September 18, 2019 and on October 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral exam (D0120) bitewing x-rays (D0274) and prophylaxis (D1110) provided by physician May 28, 2019.You asked the Plan to pay for the dental services. You say that you were advised at the plan seminar to check the website "find a doctor" to see if your doctors were in the plan and you did and your doctors were on whatever website you used.The Plan denied your request. The Plan says care rendered by a provider that is not a part of the supplemental dental network 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. For covered dental services, you must use an in-network contracted provider. physician is not an in-network contracted provider. 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 periodic oral exam (D0120) bitewing x-rays (D0274) and prophylaxis (D1110) provided by physician May 28, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (90853) provided on July 16, 2019.
You asked the Plan to pay for the mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained. The services were non-emergent and 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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90853) provided on July 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy with biopsy provided on October 7, 2019.
You asked the Plan to waive the copayment for colonoscopy with biopsy. You say that you should not have to pay this copayment when the doctor injured you during the procedure. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $250 copayment for in-network colonoscopy with biopsy at an outpatient hospital. You have been asked to pay $250 copayment for colonoscopy with biopsy. Colonoscopy with biopsy 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 colonoscopy with biopsy provided on October 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new patient eye exam (92004) and an eye refraction (92015) with out of network (OON) provider.You asked the Plan to pre-approve these services. You say that you received an injection in your eye for macular degeneration with a network provider that was painful and you later developed Bell's palsy. You want to see a non-network provider that uses another procedure to treat macular degeneration.The Plan denied your request. The Plan requires you to receive care from providers who are part of your primary care physician's specialty 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approve a new patient eye exam (92004) and an eye refraction (92015) with the out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a lumbar transforaminal epidural injection (64486LT, 64484LT, Q996, J1100) provided on August 20, 2019.
You asked the Plan to waive the copayment for a lumbar transforaminal epidural injection. You say that you were told by the provider's receptionist that you would have a $40 copayment and you did not expect a $300 copayment. You say that you did not have surgery but a procedure for 2 lower back steroid injections. The Plan denied your request. The Plan says outpatient surgery in an ambulatory surgical center has a $150 copayment. The Plan determined that the claim was processed with the incorrect copayment of $300. As per the claim, the service occurred in the ambulatory surgical center. Therefore, the correct copayment is $150.
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 outpatient surgery in an ambulatory surgical center. You have been asked to pay a $150 copayment for a lumbar transforaminal epidural injection. This service falls within the outpatient surgery in an ambulatory surgical center benefit category. The record shows that the Plan decided that the outpatient surgery occurred in an ambulatory center. 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 lumbar transforaminal epidural injection (64486LT, 64484LT, Q996, J1100) provided on August 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the out of network cataract surgery services. You say that the enrollee did not inform you that her Medicare insurance had changed. You say that you would have tried to get prior authorization for the out of network care. You say that you are willing to accept the Medicare fee allowed amount. You say that the cataract surgery was medically necessary. The Plan denied your request. The Plan says they require the utilization of in network providers unless they pre-approve out of network services in non-emergent situations.
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 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 the medical services provided on June 26, 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 hospital outpatient oncology clinic visit provided on June 25, 2019.
You asked the Plan to pay for the hospital outpatient oncology clinic visit. You say that you underwent stem cell transplant surgery in 2016, which was approved by your Plan. You say your physician advised you to have yearly screening and follow up visits at this hospital. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 hospital outpatient oncology clinic visit provided on June 25, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on October 29, 2019.You asked the Plan to waive the copayment fora diagnostic colonoscopy. You say that you received services inpatient and should not be charged for a preventative colonoscopy.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 costsharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that plan members must pay a $225 copayment for outpatient surgery performed in an outpatient hospital. The medical records show that you received a diagnostic colonoscopy in an outpatient hospital facility on October 29, 2019. Therefore, you are responsible to pay the $225 copayment. You have been asked to pay a $225 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy 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 diagnostic colonoscopy provided on October 29, 2019.