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

We decided that the Plan does not have to pay for psychotherapy services provided on August 27, 2019. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 
 
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 psychotherapy services provided on August 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 14, 2019 by an out-of-network provider.
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 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve out-of-area chemotherapy services.
You asked the Plan to pre-approve the out-of-area services. You say that you cannot get on a plane to return
home. The Plan denied your request. The Plan says that there is no urgency to treat you, and you can wait for
your plan evaluation upon return to the service area.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and
pre-approved care.
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 out-of-area services. Our physician
reviewer found that you have several chronic medical problems, and were found to have enlarged spleen and
diagnosed with a slow growing lymphoma. Extenuating circumstance is that you had fall and are unfit for
travel back home at present. There would be hardship upon the patient to get therapy at home in California.
Therefore, the requested services are medically reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the out-of-area services have been met. Therefore, we decided that the Plan has
to pre-approve out-of-area chemotherapy services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (82397, 82542, 82172, 82465) provided
on September 20, 2019 by out of network provider
You asked the Plan to pay for lab services. You say that you have had several providers within the organization
and multiple diagnostic tests for your condition. The Providers were not able to diagnose your
condition. You elected to see an outside provider that was able to diagnose your condition. Because the out-ofnetwork
doctor was able to help you, you want the procedure covered. The Plan denied your request. The Plan
says you self-directed your care to an out of plan provider without authorization from the health plan. The Plan
and Medicare rules require you to obtain covered services from plan providers except for emergency care and
out-of-area urgent care. The Plan did not authorize the lab services provided to you.
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 laboratory services (82397, 82542, 82172, 82465)
provided on September 20, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee can receive the care required at the current facility they are in. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a chronic obstructive pulmonary disease (COPD) exacerbation. The enrollee required intubation/ventilation and subsequently received a tracheotomy. The enrollee has since been weaned from the ventilator to a tracheotomy collar. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim partial mandibular denture (D5821) provided on September 10, 2019.
You asked the Plan to pay for the dental service. You say that you had a tooth extracted. You say that the dentist offered either a bridge, implant, or tooth flap and you chose the tooth flap. You also say that you are new to Medicare and assumed that since the service was offered, it would be covered. The Plan denied your request. The Plan says the interim partial denture is not a covered service.
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 interim partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the interim partial mandibular denture (D5821) provided on September 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the knee arthroscopy and anesthesia provided on September 6, 2019.
You asked the Plan to waive the cost share for the knee arthroscopy and anesthesia. You say that you were billed out-of-network. You say that you were advised the provider was in-network. The Plan denied your request. The Plan says the cost share applied correctly.
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 your deductible is $1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Your contract with the Plan says that you must pay a $250 copayment for Medicare-covered outpatient surgery after you pay your 1,000 deductible. The item or service you asked the Plan to waive the cost share for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 deductible applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the knee arthroscopy and anesthesia were received on September 6, 2019. Therefore, the remaining amount of your deductible was applied.
Since you met your deductible you have also been asked to pay a $250 copayment. The records show that you were charged the in-network rate. 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 knee arthroscopy and anesthesia provided on September 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the post-cataract surgery provided on
October 16, 2019.
You asked the Plan to waive the copayment for the post-cataract surgery. You say that you were told the
surgery would be 100% covered. The Plan denied your request. The Plan says you have been charged the
correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350
copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital
facility. For this date of service, you have been asked to pay the allowed amount of the claim because this
amount is less than the $350 copayment for outpatient surgery.
You have been asked to pay a $236.60 copayment for the post-cataract surgery. The post-cataract surgery falls
within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers" benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the post-cataract
surgery provided on October 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on September 20, 2019.
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on September 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for immunizations received on September 17, 2019.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit, but it may be available through Part D.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The
Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the services.
Therefore, we decided that the Plan does not have to pay for immunizations received on September 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of periapical x-rays (D0210) provided on September 17, 2019.
You asked the Plan to pay for the dental services. You say that the Plan is obligated to allow "at least" the amount for one set of bitewing x-rays each year. The Plan denied your request. The Plan says periapical x-rays are not a covered service.
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 complete series of periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series of periapical x-rays (D0210) provided on September 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on October 1, 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 screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on October 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you urgently need these items. The Plan denied your request. The Plan says the denial of authorization for these items is correct, because incontinence supplies are not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology testing provided on July 10, 2019.
You asked the Plan to pay for the molecular pathology testing. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 molecular pathology testing provided on July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.
You asked the Plan to pre-approve orthopaedic services. You say that you have severe arthritis and are in a lot of pain. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network orthopaedic specialist.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says that the enrollee has not tried zoledronic acid.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Prolia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings, four or more surfaces, anterior (D2335) for teeth # 23, 24, 25, 26, and 27, the fillings, four or more surfaces, posterior (D2394) for tooth # 21, and the fillings, two surfaces, posterior (D2392) for tooth # 28 provided on September 6, 2019.
You asked the Plan to pay for the fillings for teeth # 21, 23, 24, 25, 26, 27, 28. You say that The Plan denied your request. The Plan says the frequency limit has been exceeded. The Plan also says that 1 extraction per calendar year is covered per year.
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 and fillings are a covered service, the frequency limit has been exceeded. The record shows that the Plan previously paid for 1 extraction that you received on September 6, 2019. Therefore, we decided that the Plan does not have to pay for the fillings, four or more surfaces, anterior (D2335) for teeth # 23, 24, 25, 26, and 27, the fillings, four or more surfaces, posterior (D2394) for tooth # 21, and the fillings, two surfaces, posterior (D2392) for tooth # 28 provided on September 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81404, 81292, 81295, 81298, 81317, 81401, 81403) provided on May 24, 2019 by out of network provider.
You asked the Plan to pay for genetic testing. You say that you are requesting the policy be reviewed and re-process the claim for payment. The Plan denied your request. The Plan says non-urgent services are not authorized because the provider is a non-network provider that does not work with the health plan. The ordering provider is also a non-network provider. The member's primary care provider did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 genetic testing (81404, 81292, 81295, 81298, 81317, 81401, 81403) provided on May 24, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered 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 Ozempic.  
 
Benefits for Ozempic may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.