Persius/hicric huggingface dataset:
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 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without 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 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 October 14, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox to be picked up at a pharmacy and brought to the office for injection.
You asked the Plan to pre-approve the Botox. You say that the enrollee requires this medication for treatment of her migraines. The Plan denied your request. The Plan says this is not covered by Part B unless it is provided from the treating physician's stock. Part D would cover it if it is dispensed by the pharmacy.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Botox to be picked up at a pharmacy and brought to the office for injection.
Benefits for the Botox 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 physician's services provided on December 17, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services.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 physician's services provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services provided by an in-network facility on December 20, 2019. You asked the Plan to waive the copayment for urgent care services. You say that you did not know that there would be a price difference. You say that you went to the clinic and they were closed. You say that there was a sign that told you to go to urgent care. The Plan denied your request. The Plan says the correct copayment has been applied. 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 $50 copayment for urgently needed services. You have been asked to pay a $50 copayment for urgent care services. Urgent care services fall within the urgently needed 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 urgent care services provided by an in-network facility on December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the dermatology services. You say that you would like reconsideration as you believe these services should be covered by the Plan. The Plan denied your request. The Plan says the out-of-network services were not urgent/emergent and could have reasonably provided in-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 the medical services provided on December 18, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an enterectomy (44120 and 44121) provided on August 15, 2019.
You asked the Plan to pay for the enterectomy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says certified surgical technicians are not recognized for payment per the Center for Medicare/Medicaid Services (CMS) guidelines.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for an enterectomy (44120 and 44121) provided on August 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 12, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says 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 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on November 1, 2019.
You asked the Plan to pay for the dental services. You say that your body builds excess tartar on your teeth. You also say that your dentist recommends you have your teeth cleaned every 4 months rather than every 6 months. The Plan denied your request. The Plan says 2 oral exams and 2 prophylaxis are covered per plan year. The Plan also says that the frequency limits for the oral exam and prophylaxis have been exceeded.
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 record shows that the Plan previously paid for these services that you received on January 8, 2019 and July 18, 2019. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on November 1, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cystoscopy provided by an in-network hospital on November 18, 2019.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you were never told that switching the location of the surgery would change your copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $325 copayment for outpatient surgery/outpatient hospital. You have been asked to pay a $325 copayment for an outpatient surgery. The correct copayment has been applied for the services that were provided. An outpatient surgery falls within the outpatient surgery/outpatient hospital benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a cystoscopy provided an in-network hospital on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for brachytherapy provided on June 13, 2019.You asked the Plan to pay for the brachytherapy. The Plan denied your request. The Plan says prior authorization was required 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 did not pre-approve the servicesat 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 brachytherapy provided on June 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by an in-network hospital on September 24, 2019.You asked the Planto waive the copayment for an outpatient surgery. You say that you did not have a surgical procedure done. The Plan denied your request. The Plan says the correct copayment has been applied.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 $345 copayment for outpatient surgery/in-network/outpatient hospital. You have been asked to pay $277.45 which is less than your copayment amount of $345 for an outpatient surgery. The vaginal device insertion is considered an outpatient surgery; therefore, the correct copayment has been applied. an outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital 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 outpatient surgery provided by an in-network hospital on September 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient physical therapy (PT) visits
rendered to you on October 28, 2019 to December 12, 2019.
You asked the Plan to waive the copayments for these services. You say that the provider's office assured you
that you would not be charged. The Plan denied your request. The Plan says the copayments were 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 $40
copayment for each Medicare-covered therapy visit.
Review of the file shows that you had four PT visits from October 28, 2019 to December 12, 2019. You have
been asked to pay a $40 copayment per visit for these services, for a total of $160. These services fall within
the Medicare-covered therapy visit 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. The Plan cannot be held responsible for possible misinformation regarding your
coverage given by a provider. Therefore, we decided that the Plan does not have to waive the copayments for
the outpatient physical therapy (PT) visits rendered to you on October 28, 2019 to December 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Pantoprazole Sodium 40mg tablet medication (J8499).
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial as this medication is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee has a medical (MA) only policy, not a Prescription Drug Plan (PDP). Therefore, 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Pantoprazole Sodium 40mg tablet medication (J8499).
Benefits for this medication 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 the medical services provided on October 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the sclerosant injection (36471) and ultrasonic guidance (76942). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.
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 October 16, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient clinic services provided on April 8, 2019.
You asked the Plan to waive the copayment for the outpatient clinic services. You say that your procedure was performed in an outpatient clinic and not a hospital. The Plan denied your request. The Plan says that you are responsible for a $30.00 copay for services rendered in a specialist office.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copay for specialist services. You have been asked to pay a $30 copay for the outpatient clinic services. The outpatient clinic services fall within the specialist 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 the outpatient clinic services provided on April 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on November 5, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says 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 has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for telehealth services provided by an innetwork
specialist on February 24, 2019.
You asked the Plan to waive the copayment for telehealth services. You say that you did not see a doctor on
this day. You say that you spoke over webcam but that was it. The Plan denied your request. The Plan says the
correct copayment has been applied.
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 $45
copayment for physician/practitioner services/specialist services.
You have been asked to pay a $45 copayment for telehealth services. Telehealth services fall within the
physician/practitioner services/specialist 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 telehealth services provided by an in-network specialist on February 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Myocardial Perfusion Imaging (78452) provided May 24, 2019 by the provider.
You asked the Plan to pay for the Myocardial Perfusion Imaging. You say that the imaging was medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.
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 pay for the Myocardial Perfusion Imaging. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Based on the records the patient has increased cardiac risk but no documented cardiac symptoms, a normal cardiac physical exam and a normal electrocardiogram schedule for elective carotid endarterectomy. In this circumstance of no cardiac symptoms or abnormal cardiac findings and a low risk noncardiac surgery, preoperative stress testing is not considered appropriate. 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 Myocardial Perfusion Imaging have not been met. Therefore, we decided that the Plan does not have to pay for Myocardial Perfusion Imaging (78452) provided May 24, 2019 by the provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 13, 2019 through September 15, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the medical records provided indicate that the admitting physician expected the enrollee's admission to span two midnights. Care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. She had stable vital signs and no complaints at the time of admission. Orders included telemetry, adjustment of oral medications. Inpatient services were not supported by the documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 13, 2019 through September 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on October 2, 2019 by
an out-of-network provider.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. The information received did not
show the requested service claim has not already paid on December 12, 2019. Therefore, we decided that the
Plan does not have to pay for the services provided to the enrollee on October 2, 2019 by an out-of-network
provider.