Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on June 28, 2019.
You asked the Plan to pay for the dental services. You say that this was an emergency visit because your crown fell out. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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. You exhausted your benefit frequency limit. Your EOC only provides a benefit for two dental examinations per calendar year, and your claims record shows that payment was made for dental examinations on April 1, 2019 and April 23, 2019. Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on June 28, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections.
You asked the Plan to pre-approve Euflexxa. You say that you cannot make it from one room to another. The Plan denied your request. The Plan says you have not had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our physician reviewer found that you have bilateral osteoarthritis of the knees. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The documentation does not show that you have tried and failed the required drugs. The documentation does not support that Orthovisc and Monovisc would likely be less effective, or would likely have adverse effects. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the information submitted did not meet the guidelines.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for intracranial hemorrhage, for which neurosurgery was performed. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee is noted to be tolerating ventilator weaning. The enrollee's long-term neurologic prognosis is unclear. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on November 13, 2018 by an out of network (OON) provider.
You asked the Plan to pay for the out-of-network services. You say that the enrollee provided only a Medicare card. The Plan denied your request. The Plan says out-of-network providers require 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 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 out-of-network services. Therefore, we decided that the Plan does not have to pay for the vision services provided on November 13, 2018 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe train of four testing provided February 28, 2019.You asked the Plan to pay forthe train of four testing. You say that the services were medically necessary and the ordering physician determined that the enrollee met the criteria for intraoperative neurophysiological monitoring.The Plan denied your request. The Plan says train of four is considered a bundled procedure and payment is included in the payment of the primary procedure, neurophysiological monitoring.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that the train of four testing has a bundled relationship with code 51785 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forthe train of four testing provided February 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the clinical documentation is clear and demonstrates medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits.
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 services at issue. We found no exception that would require the Plan to pay for these out-of-network services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 14, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 29, 2019 by an out of network (OON) provider.You asked the Plan to pay foroffice visit. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The 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 payforthe medical services provided on October 29, 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 the an office visit (99205) and related services (94729, 94060, J7620, and 94726) provided on April 25, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the an office visit and related services. You say that the enrollee did not say he was enrolled in the Plan. The Plan denied your request. The Plan says these services were not authorized.
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 an office visit (99205) and related services (94729, 94060, J7620, and 94726) provided on April 25, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe compact oxygen concentrator purchased on August 9, 2019.You asked the Plan to reimburse you forthe compact oxygen concentrator. You say that you had a prescription and you were told you would be reimbursed 80%.The Plan denied your request. The Plan says you did not have prior authorization for the 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 reimburse you 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 itemsat issue in this appeal. The Plan did not pre-approve the itemat issue. We found no exception that would require the Plan to reimburse you for these items.Also, purchased oxygen equipment is statutorily not covered by Medicare. Therefore, we decided that the Plan does not have to reimburse you forthe compact oxygen concentrator purchased on August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuropsychological testing (96118 and 96119) provided on May 24, 2018.
You asked the Plan to pay for the neuropsychological testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include documentation of the total time of the encounter that was spent performing this testing.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 96118 and 96119 are not supported in the record. Specifically, there is insufficient information to determine whether payment is due and the amount of payment. Based on this information, we decided that Medicare rules for coverage of the neuropsychological testing have not been met. Therefore, we decided that the Plan does not have to pay for neuropsychological testing (96118 and 96119) provided on May 24, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for debridement provided on November 5, 2019 and November 21, 2019.
You asked the Plan to waive the copayments for debridement. You say that you did not receive a surgical procedure and 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 $200 copayment for each outpatient hospital facility visit for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received debridement on November 5, 2019 and November 21, 2019. Debridement is considered a surgical procedure. Therefore, you are responsible to pay the allowed amount of $174.31 per each service. The total amount you owe is: $348.62. You have been asked to pay the total copayment amount of $348.62 for debridement. Debridement 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 copayments for debridement provided on November 5, 2019 and November 21, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve left knee arthroscopy, debridement, medial meniscectomy, loose body removal, and possible chondroplasty.
You asked the Plan to pre-approve the requested knee surgery. You say that the enrollee would benefit from this surgery. The Plan denied your request. The Plan says that imaging does not show severe arthritis and there has not been enough recent conservative therapy.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 requested knee surgery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee presents with a 6-month history of persistent left knee pain with intermittent swelling and catching. She reports that she intermittently feels like she might fall. Clinical exam findings have documented medial joint line tenderness and positive test consistent with imaging evidence of a large complex medial meniscus tear and loose bodies within the joint capsule. There is radiographic evidence of minimal/mild features of degenerative arthritis. Reasonable conservative treatment, including activity modification and medication, has failed to provide improvement over the prior 6 months. Under consideration is a request for left knee meniscectomy. Current evidence based medical literature supports surgical intervention at this time based on subjective complaints, mechanical signs, physical exam, imaging findings, reported minimal arthritis, and failed conservative treatment. Therefore, in this reviewer's opinion, the requested left knee meniscectomy is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested knee surgery have been met. Therefore, we decided that the Plan has to pre-approve left knee arthroscopy, debridement, medial meniscectomy, loose body removal, and possible chondroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 9, 2019 by an out of network (OON) provider.You asked the Plan to pay for the cerumen removal (69210). You say that this service was necessary in order to adjust the member's hearing aids. The Plan denied your request. The Plan says utilization of in-network providers is required unless the Plan pre-approve out-of-network services in a non-emergent situation.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 August 9, 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 copayment forthe joint injection on October 9, 2019.You asked the Plan to waive the copayment forthe joint injection. You say that you went to the facility for a routine follow-up, a flu shot, and a prescription renewal. You say the service was performed in a doctor's exam room and the charge is unfair. 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 $415 copayment for Medicare-covered surgeryor other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $415 copayment for the joint injection.You have been asked to pay a $227.29 copayment for the joint injection. The joint injection falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows you received the injection and 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 waive the copayment forthe joint injection provided on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 24, 2019
by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services were rendered in good faith. The
Plan denied your request. The Plan says the services were not authorized, nor requested by an in-network
physician.
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 services at
issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided
that the Plan does not have to pay for the medical services provided on June 24, 2019 by an out of
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral to  an out-of-network provider.You asked the Planto pre-approvethe referral. You say that you would like an exception to be made for this provider.The Plandenied your request. The Plansaysthere are in-network providers available.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plandoes not haveto pre-approvea referral to an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Zoster vaccine rendered to the enrollee on September 26, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to these services.Therefore, we decided that the Plan does not have to pay forthe Zoster vaccine rendered to the enrollee on September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis provided on October 14, 2019.
You asked the Plan to pay for the knee orthosis (L1833). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the documentation submitted did not include a delivery ticket or proof of delivery for the billed orthosis.
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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the knee orthosis provided on October 14, 2019.