Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided to the enrollee on July 17, 2019.You asked the Plan to pay for this claim. You say that this claim should be paid.The Plan denied your request. The Plan says this service was ordered by a non-plan provider and the enrollee did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan mustpay 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 forpathology services provided to the enrollee on July 17, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Room services (93005, 99283, 72152, 7045) provided February 26, 2019.
You asked the Plan to pay for the Emergency Room Services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim must first be submitted to the enrollee's auto insurer as the claim was the result of an accident, or proof of no auto insurance must be provided before the plan can process the claim.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has attempted to obtain an EOB or proof of no coverage from the auto insurer. As the secondary insurer, the Plan cannot be held responsible for the Emergency Room Services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for Emergency Room services (93005, 99283, 72152, 7045) provided February 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBT).
You asked the Plan to pre-approve PBT. You say that this is covered by Medicare. The Plan denied your request. The Plan says the treatment requested is not known to be more effective than other types of RT (radiation therapy).
The Plan follows Medicare rules. Medicare rules say that PBT is considered reasonable in instances where sparing the surrounding normal tissue cannot be adequately achieved with photon-based radiotherapy. 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 PBT. Our reviewer says that the criteria for coverage of PBT have not been met. Our physician reviewer found the record shows that photon based intensity-modulated radiation therapy can adequately spare normal tissues. There is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PBT have not been met. Therefore, we decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBT).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe nuclear medicine test provided on September 19, 2019.You asked the Plan to waive the copayment forthe nuclear medicine test. You say that you were informed there would be a $50 copayment. You say that you would not have had the test if you knew about the higher copayment.The Plan denied your request. ThePlan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375 copayment for Medicare-covered diagnostic radiology services in an outpatient hospital setting.You have been asked to pay a $375 copayment for nuclear medicine test. The nuclear medicine test 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 forthe nuclear medicine test provided on September 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Uloric for the enrollee.
You asked the Plan to pre-approve Uloric. You say that the enrollee has done well with Uloric in the past. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Uloric for the enrollee.
Benefits for Uloric may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on October 3, 2019 by out of network provider.You asked the Plan to pay for an office visit. You say that you do not agree with this decision and the notes sent support the need for service.The Plan denied your request. The Plan says the rendering provider  is a non-participating provider. The plan did not authorize any services for provider. There are multiple in-network providers within 30 miles of the member's residence that could have rendered the services. The services are not considered urgent/emergent in nature.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 (99214) provided on October 3, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea queen-sized adjustable bed.You asked the Plan to pre-approvequeen-sized adjustable bed. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this bed is not primarily medical in nature and is not covered by Medicare.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea queen-sized adjustable bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered to you on September 27, 2019.You asked the Plan to pay for these services. You say that you asked for a chiropractic adjustment and that is what you received.The Plan denied your request. The Plan says the services are not covered when performed by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The provider submitted a claim for procedure code 99202 (office visit).Therefore, we decided that the Plan does not have to pay for the office visit rendered to you on September 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe injection provided on June 11, 2019.You asked the Plan to waive the copayment forthe injection. You say that the copayment has never been this high before. You say that you were not informed the copayment would be this high.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.You have been asked to pay a $250 copayment for the injection. The injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The injection is considered a surgical procedure. 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 injection provided on June 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection (62323) provided at an ambulatory surgical center on September 16, 2019.
You asked the Plan to waive the copayment for an injection provided at an ambulatory surgical center. You say that you cannot afford this charge. The Plan denied your request. The Plan says this service processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $180 copayment for surgical services at an ambulatory surgical center. You have been asked to pay a $180 copayment for an injection provided at an ambulatory surgical center. An injection falls within the surgical services 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 an injection (62323) provided at an ambulatory surgical center on September 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance service provided on November 20, 2018.You asked the Plan to pay for the ambulance service (A0428HR). You say that the Plan should pay this claim.The Plan denied your request. The Plan says this service was not authorized.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for thedates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe ambulance service provided on November 20, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA 1 and 2 testing (81162).You asked the Plan to pre-approve BRCA 1 and 2 testing (81162). You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested BRCA 1 and 2 testing.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. Medicare guidelines say that BRCA1/BRCA2 testing is not covered for individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer. Such testing is considered screening and is excluded by Medicare. In this case, the file shows you have a family history of cancer; however, the file does not show that you have a personal history of cancer. Based on this information, we decided that Medicare rules for coverage of BRCA 1 and 2 testing (81162) have not been met.Therefore, we decided that the Plan does not have to pre-approveBRCA 1 and 2 testing (81162)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the enrollee is at high risk of infection and falls. You say that the enrollee is recovering well but is unaware of what is going on around her.The Plan denied your request. The Plan says the enrollee could receive care in another setting. The Plan says that the guidelines for coverage of IRF care have not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. The enrollee is mostly minimal assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have notbeen met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided on July 23, 2019 by an out of network provider.
You asked the Plan to pay for an office visit. You say that the rendering provider was covering for your primary care physician who was on vacation on the date of service. You did not think to call the Plan and request pre-approval. You are requesting the plan to review this and reconsider payment of the denied claim. The Plan denied your request. The Plan says the provider does not participate with the health plan. A letter was sent to non-contracted provider for the claim that was submitted, to complete and return, so that the plan could assess if payment could be approved based on services being urgent or emergent. The non-contracted provider did not send in a response to the Plan. The plan contract states that while you are a member of the plan, you must use network providers to get medical care and services. The claims do not meet the urgent or emergent criteria. The member is enrolled in an HMO plan with no out of network benefits. There is no documentation this member was referred to this non-contracted provider by a contracted provider, as well as no indication any attempt was made to obtain prior authorization for this out of network service. The health plan has located several available in-network providers who are able to perform the requested 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 an office visit (99203) provided on July 23, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from November 2, 2018, to November 30, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 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 medical services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLexis Light foldable scooter (E1399).You asked the Plan to pre-approveLexis Light foldable scooter. You say that you believe that this decision is erroneous and is request review of additional evidence from your health care provider.The Plan denied your request. The Plan says this enrollee does not meet the required criteria for coverage and is not medically necessary.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 Lexis Light foldable scooter. Our reviewer says that this enrollee does not meet the criteria for the requested lightweight foldable scooter. Our physician reviewer found the medical records did not contain a detailed mobility evaluation. The records do not support the enrollee has a personal mobility deficit that impairs participation in mobility related activity of daily living. The records indicate he can ambulate household distances without getting shortness of breath. The records do not support the enrollee's mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair. The records do not support the enrollee can safely operate the PMD.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lexis Light foldable scooter have not been met.Therefore, we decided that the Plan does not have to pre-approveLexis Light foldable scooter (E1399).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing provided to the enrollee on March 25, 2019.You asked the Plan to pay forthe testing services. The Plan denied your request. The Plan says the codes billed are inclusive to the primary procedure and are not separately reimbursable.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 file shows that drug testing services at issue were billed, as coded by 80156, 80157, 80177, 80201, 80162, 80159, and 80173. The records show that definitive drug testing, G0480, was billed and paid for by the plan.The records do not show that additional testing was provided to justify billing the individual tests separate from the definitive drug testing billed and paid for by the plan. Procedures shall be reported with the most comprehensive CPT code that describes the services performed. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have topay forthe drug testing provided to the enrollee on March 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea bone replacement graft for ridge preservationYou asked the Planto pre-approvethe services. You say that you are appealing because of your medical history and status.The Plandenied your request. The Plansaysthis procedure is not covered.Medicare generally does not cover dentalservices. 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 arenot among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approvea bone replacement graft for ridge preservation
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe psychiatric diagnostic evaluation provided on September 17, 2019.You asked the Plan to reduce the copayment forthe psychiatric diagnostic evaluation. You say that you should be covered with a $15 copayment. The Plan denied your request. The Plan says the claim has been reprocessed to reflect the correct cost sharing amountThe 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 $40 copayment at an in-network specialist's office. You have been asked to pay a $40 copayment for the psychiatric diagnostic evaluation. The psychiatric diagnostic evaluation falls within the "Outpatient mental health 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 toreduce the copayment forthe psychiatric diagnostic evaluation provided on September 17, 2019.