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

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on September 29, 2020.

You asked the Plan to pay for the home visit. You say that the physician depends on the hospital staff to verify eligibility and obtain proper authorization. You say that the doctor should not be penalized, and the claim should be considered for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

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 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 home visit provided by an out-of-network provider on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mouth guard (D9944).
You asked the Plan to pre-approve a mouth guard. You say that you want the Plan to pay for the service. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 3 Plan years.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a mouth guard have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on February 14, 2019. Therefore, we decided that the Plan does not have to pre-approve a mouth guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites, mandibular partial denture, and maxillary partial denture provided from September 3, 2020, to October 8, 2020.

You asked the Plan to pay for the resin-based composites, mandibular partial denture, and maxillary partial denture. You say that you thought these services would be covered. The Plan denied your request. The Plan says these services are 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. 

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 the two resin-based composites, mandibular partial denture, and maxillary partial denture provided from September 3, 2020, to October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9944).

You asked the Plan to pre-approve an occlusal guard. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 3 years.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an occlusal guard have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on September 19, 2020. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychological or neuropsychological test administration provided on December 7, 2020 by an out of network provider.

You asked the Plan to pay for Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; first 30 minutes (96136). You say that you understand you requested authorization for a different code, but the provider has billed this code. The Plan denied your request. The Plan says you did not request prior authorization 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 had network providers available who could have provided 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 this service. Therefore, we decided that the Plan does not have to pay for the psychological or neuropsychological test administration provided on December 7, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 22, 2021 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that no one told you that you needed to see a primary care provider prior to seeing this doctor, and you are on a fixed income. 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 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 had 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 an office visit provided on January 22, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home care services provided from September 11, 2020 to October 31, 2020.
You asked the Plan to pay for home care services. You say that these services were necessary. The Plan denied your request. The Plan says these services were not billed with CPT codes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We find that sufficient information to determine whether the services at issue are covered has not been submitted. Specifically, an itemized bill from the provider using CPT codes has not been received. The record shows that the Plan made several attempts to obtain this information without success. Based on this information, we decided that Medicare rules for coverage of home care services have not been met. Therefore, we decided that the Plan does not have to pay for home care services provided from September 11, 2020 to October 31, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper endoscopy for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation fails to indicate a recent negative colonoscopy.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pre-approve the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee meets none of the listed LCD criteria. The records do not support iron deficiency, nor active or recent UGI hemorrhage to warrant this request as medically 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an upper endoscopy for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on October 6, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you were told that all copayments were being waived through the end of 2020. You say the copayment is a hardship. The Plan denied your request. The Plan says you have been asked to pay 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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The Plan says the cost share waiver was only active through September 30, 2020. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit provided on October 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation service (A0428) provided on November 2, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 Medicare-covered one-way ground ambulance benefit. 

You have been asked to pay a $150 copayment for the one-way Medicare-covered ground ambulance service provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation service (A0428) provided on November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for triamcinolone acetonide injections (J3301) provided on November 3, 2020.

You asked the Plan to pay for triamcinolone acetonide injections. You say that this was billed correctly. The Plan denied your request. The Plan says this code is not supported.

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 J3301 is injection, triamcinolone acetonide, not otherwise specified, 10 mg.

We find that CPT code J3301 is not supported in the medical record. Specifically, there is no documentation of triamcinolone acetonide being administered on this date of service.. Based on this information, we decided that Medicare rules for coverage of triamcinolone acetonide injections have not been met. Therefore, we decided that the Plan does not have to pay for triamcinolone acetonide injections (J3301) provided on November 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the outpatient hospital services provided October 17, 2019 to October 19, 2019.

You asked the Plan to waive the co-payment for the outpatient hospital services. You say that at the time of this service your out-of-pocket expenses were paid and this should have been covered 100%. The Plan denied your request. The Plan says your out of pocket for 2019 was not met. The claim was processed and the correct cost share was applied per the Evidence of Coverage.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $275 copay for Medicare covered outpatient hospital services.

You have been asked to pay $112.00 for the outpatient hospital services. The outpatient hospital services fall within the Outpatient hospital care benefit category. The in-network maximum out of pocket is $5,900 and combined maximum out of pocket is $10, 000 per calendar year. You paid $5,803 towards your combined out of picket. 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 co-payment for the outpatient hospital services provided October 17, 2019 to October 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy, 45 minutes (90834) provided on May 27, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that the rendering physician, provider is a hospitalist physician with a group and depends upon the hospital staff to verify eligibility and obtain proper authorization from insurance companies. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 had 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 individual psychotherapy, 45 minutes (90834) provided on May 27, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (G0277).

You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be limited to that which is administered in a chamber (including the one man unit) and is limited to the indicated conditions.

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 this service. Our reviewer says that this service is not medically necessary. Our physician reviewer found that based on the medical records provided, there is no specific diagnosis given for the recommendation for hyperbaric oxygen in relation to the extraction of teeth. The Medicare criteria for hyperbaric oxygen therapy are not met and it is therefore, not considered medically 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (G0277).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says there is no authorization on file for the services.

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 file shows that definitive drug testing was provided. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 18, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for phlebotomy provided on December 10, 2020.

You asked the Plan to waive the copayment for phlebotomy. You say that this procedure is beneficial and you 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 $100 copayment for diagnostic procedures and tests provided in an outpatient hospital facility. 

You have been asked to pay the allowed amount of $96.26, which is less than the $100 copayment for phlebotomy. Phlebotomy falls within the outpatient diagnostic tests and therapeutic services and supplies 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 phlebotomy provided on December 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99232, 99233) provided from October 2, 2020, to October 6, 2020.
You asked the Plan to pay for hospital care. You say that this was billed with the correct diagnoses. The Plan denied your request. The Plan says the billed primary diagnosis is incorrect.
The Plan must follow Medicare rules. Medicare rules say that conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. We looked at the file and Medicare rules. The billed primary diagnosis, E08.621, diabetes mellitus due to underlying condition with foot ulcer, is a manifestation code. The underlying condition must be sequenced first, meaning this is not a valid primary diagnosis. Based on this information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99232, 99233) provided from October 2, 2020, to October 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the split-night sleep study (95811) provided on May 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the sleep study. You say that you received a bill and you do not remember going to this facility. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 had 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 split-night sleep study (95811) provided on May 28, 2020 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 established patient home visit (99350) provided on December 16, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the established patient home visit. You say that prior authorization was not obtained for these services rendered by an OON provider. The Plan denied your request. The Plan says these services were medically necessary.

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 had 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 established patient home visit (99350) provided on December 16, 2020 by an out of network (OON) provider.