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

We decided that the Plan has to pay for psychiatry services provided on February 15, 2019 through October 8, 2019.
You asked the Plan to pay for the psychiatry services. You say that you would like reconsideration because you were advised that you could continue care with this provider. The Plan denied your request. The Plan says that your visits with this provider were not payable because this provider does not accept Medicare payments.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There is no documentation to show that you were not aware that the provider was not taking Medicare Payment. Additionally, the Plan authorization says the you and the physician would be notified if the Plan chose to end the authorization early. There is no documentation to show that the Plan notified you that the authorization would be expiring early. Therefore, we decided that the Plan has to pay for psychiatry services provided on February 15, 2019 through October 8, 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network mental health services provided on August
22, 2019 at the in-network rate.
You asked the Plan to pay for this service at the in-network rate. You say that you were told by the provider
that they were in network. The Plan denied your request. The Plan says it was confirmed that this provider is
not in network and at the time of service, the deductible had not been met.
Medicare rules say that plans must clearly explain cost share expectations in the Plan contract. The contract
with the Plan says there was a deductible for both in network and out of network services. The provider in this
case is not a network provider with the Plan. The contract clearly states out of network providers will require a
higher cost share for both the deductible and the cost share for each service. At the time of service, the innetwork/
out of network combined total deductible had not been met. Therefore, we decided that the Plan does
not have to pay for out of network mental health services provided on August 22, 2019 at the in-network rate.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology and lab services provided on December 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the radiology and lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were 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 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 radiology and lab services provided on December 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 CPT Code G0481 provided on September 9, 2019.
You asked the Plan to pay for CPT Code G0481. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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, the CPT Code Manual definition of code G0481 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed. We find that CPT code G0481 is not supported in the medical record. Specifically, the record does not contain evidence that definitive testing on 8-14 drug classes was performed. Based on this information, we decided that Medicare rules for coverage of CPT Code G0481 have not been met. Therefore, we decided that the Plan does not have to pay for CPT Code G0481 provided on September 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora raised toilet seat (E0244)  a Transport Chair (E1038)  provided October 28, 2019 and November 2, 2019.You asked the Plan to pay forthe toilet seat and transport chair. You say that the items were medically necessary.The Plan denied your request. The Plan says the toilet seat is not a covered item, and the Wheelchair was provided by a provider that does not participate in Medicare.The Plan must follow Medicare rules. Medicare rules say that toilet seats and bidets are not covered. Rules also say that payment cannot be issued for items or services provided by providers who have opted out of Medicare.We lookedat the file and Medicare rules. The raised toilet seat is not a covered benefit. The record shows that Lakeside Pharmacy only participates in Medicare Part D for prescription drugs. They are not a Medicare authorized dealer of Durable Medical Equipment, such as wheelchairs. Payment for such items can only be issued to providers that participate in the Medicare program. Based on this information, we decided that Medicare rules for coverage of the toilet seat and transport chair. have not been met.Therefore, we decided that the Plan does not have to pay fora raised toilet seat (E0244)  and a Transport Chair (E1038) provided October 28, 2019 and November 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and an x-ray provided on October 23, 2019 by an out of network (OON) provider. You asked the Plan to pay for an office visit and an x-ray. You say that your office did the reconstructive surgery in 2012. You say that a screw was working its way out on the top of the foot. 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 and an x-ray provided on October 23, 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 medical services provided on July 18, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for the office visit (99204) provided on July 18, 2019. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim
processed correctly according to the member's Evidence of Coverage and prior authorization was not requested
for this service.
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 by
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have previously tried injections on your toes. You say that it is hard for you to walk and you really need the requested inserts. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from December 3, 2019 to December 24, 2019.You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the facility claim has been billed with the incorrect type of bill code.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim has been submitted with an invalid type of bill code for home health services.Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from December 3, 2019 to December 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (G0481) provided on September 25, 2018.
You asked the Plan to pay for the laboratory services (G0481). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services (G0481) provided on September 25, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for podiatry services. You say that you pay a premium every month and deserve full benefits. 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 10, 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 nurse practitioner services provided on January 31, 2020.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 nurse practitioner services provided on January 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided on January 3, 2020.
You asked the Plan to waive the copayment for wound debridement. You say that you feel that the EOC does not clearly indicate the cost-sharing charges and you disagree with how the procedure was billed a surgery. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $295 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The enrollee received wound debridement on January 3, 2020. Wound debridement is considered an outpatient surgical procedure. Therefore, the enrollee is responsible to pay the $295 copayment. The enrollee has been asked to pay a $295 copayment for wound debridement. Wound debridement falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for wound debridement provided on January 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 17, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for physician services. You say that these services were medically necessary. You
say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The
Plan says no prior authorization was obtained. The Plan says 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 physician services provided on December 17,
2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis and suspension sleeve, and knee control condylar pad provided on August 14, 2019.You asked the Plan to pay forthe knee orthosis (L1833) and suspension sleeve (L2397), knee control condylar pad (L2810). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the information submitted does not justify payment.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthosis (L1833) and suspension sleeve (L2397),knee control condylar pad (L2810) have not been met.Therefore, we decided that the Plan does not have to pay forthe knee orthosisand suspension sleeve, and knee control condylar pad provided on August 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT guidance for placement of radiation therapy fields (77014) provided on October 22, 2019 through October 24, 2019.You asked the Plan to pay for the CT guidance. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the billed service is considered as part of a more extensive procedure and was reported within 14 days of CPT code 77301 for the same diagnosis.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 code 77014 is not supported in the record. Specifically, payment for 77014 is included in the APC payment for CPT code 77301. Based on this information, we decided that Medicare rules for coverage of the CT guidance have not been met.Therefore, we decided that the Plan does not have to pay forCT guidance for placement of radiation therapy fields (77014) provided on October 22, 2019 through October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 24, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for laboratory tests. You say that you processed the specimen according to the order
of the physician. 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 the ordering physician is also out-of-network
with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 September 24,
2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on December 11, 2019.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you were told by the Plan that this provider was in-network. The Plan denied your request. The Plan says this service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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. The Plan contract says that they cover bitewing x-rays, but do not cover complete series of intraoral x-rays. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the specialist office visit provided on November 11, 2019.
You asked the Plan to waive the deductible for the specialist office visit. You say that you only have a $40 copayment for the office visit. 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. Your contract with the Plan says that there is a $1,500 deductible that applies towards out-of-network specialist office visits.
The specialist office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,500 deductible that applies towards an out-of-network specialist's office. The allowed amount for the specialist office visit is $112.61. Therefore, $112.61 is the amount that is applied to your deductible. The record shows the provider is out-of-network.
This cost sharing is a contractual obligation that had not been met at the time the specialist office visit was received on November 11, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the specialist office visit provided on November 11, 2019.