Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided by an out of network provider.

You asked the Plan to pay for the vision services (92341). You say that the enrollee asked for a vision exam. The Plan denied your request. The Plan says you did not have authorization for the non-urgent 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 these services. Therefore, we decided that the Plan does not have to pay for the vision services provided by an out of network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy by an out of network provider.

You asked the Plan to pay for psychotherapy. You say that the physician provided medically necessary services and the services meet recognized standards of healthcare. You say that the claim should be processed for payment. The Plan denied your request. The Plan says services should be received from network providers.

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 psychotherapy by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says predictive screening testing is not a Medicare benefit.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found DNA probe testing for Chlamydia, Neisseria, HPV, Trichomonas was ordered along with U/A. There was no evidence of having tested for culture with equivocal results which is standard for STD screening. DNA probe does not provide additional benefit in this setting. Therefore, this request for such will be considered not 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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of an implant body services for teeth 4, 6, 18, and 20 identified with code D6010 and bone graft services identified with code D6104.

You asked the Plan to pre-approve surgical placement of an implant body services and bone graft services. You say that you lost one of the right lateral frontal teeth and you are in urgent need to fix these. The Plan denied your request. The Plan says the requested services are not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placement of an implant body services for teeth 4, 6, 18, and 20 identified with code D6010 and bone graft services identified with code D6104.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), first
intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), bitewings (D0274), and
preventive procedure (D1999).

You asked the Plan to pay for the comprehensive periodontal evaluation, intraoral periapical x-rays, bitewings,
and preventive procedure. You say that you told the provider that you only wanted to receive services that were
covered by your plan. The Plan denied your request. The Plan says these services are not covered. The Plan
also says that you did not elect to purchase an optional supplemental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
comprehensive periodontal evaluation (D0180), first intraoral periapical x-ray (D0220), each additional
intraoral periapical x-ray (D0230), bitewings (D0274), and preventive procedure (D1999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share for the oral evaluation (D0120).

You asked the Plan to waive the out of network cost share for the dental service. You say that you are visually disabled. You say that you take public transportation to doctor appointment. You say that there are no in network dentists in your area. You say that the closest is 45 minutes away by car. You say that you must utilize local public transportation and be forced to pay higher dental costs. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that you may be billed by the out of network provider for any amount greater than the payment made by the Plan to the provider. The Plan says that there are 2 in network dentists available within several miles of your home address. The Plan also says that there are transportation services available.

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, you may be billed by the out of network provider for any amount greater than the payment made by the Plan to the provider. Additionally, there are in network dentists available within your area. Therefore, we decided that the Plan does not have to waive the out of network cost share for the oral evaluation (D0120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine (90471).

You asked the Plan to pay for the shingles vaccine. You say that you would like reconsideration because you received the vaccine during your physical. The Plan denied your request. The Plan says this service is not covered by your medical plan.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90471).

Benefits for the shingles vaccine 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-emergent transportation services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve OON non-emergent transportation services. You say that the enrollee needs this transportation to get to dialysis appointments. The Plan denied your request. The Plan says this transportation is available 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

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 non-emergent transportation services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for an outpatient surgery provided by a participating provider.

You asked the Plan to reduce the coinsurance for an outpatient surgery. You say that you would like this amount reduced. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for outpatient surgery/in-network.

You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total allowed amount is $20,333.50. The total amount you are being asked to pay is $4,066.70 ($20,333.50 x 20% = $4,066.70). The correct coinsurance has been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/in-network 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 reduce the coinsurance for an outpatient surgery provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for partial payment adjustment for the inpatient hospital services.

You asked the Plan to pay for the inpatient hospital services. You say that the plan requested DRG charge from 853 to 659 with deletion of HCPCS code A41.9 and R65.21. You disagree with this decision. The Plan denied your request. The Plan says that the plan says payment of DRG 853 is not supported. The medical records submitted supports DRG 659.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to change DRG 853 to DRG 659. In this case specific records or information was required to substantiate the plans denial. The required records were missing from the original file. A request for information was sent to the health plan. As of the date of this letter, the plan has not responded to our request and/or submitted the required records. Therefore, we decided that the Plan has to pay for partial payment adjustment for the inpatient hospital services.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says members
must use network (contracted) providers to get medical care and services. The only exceptions are emergencies,
urgently needed services when the network is not available, and cases in which the Plan authorizes use of
out-of-network providers.

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 physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent
or emergent, nor were they 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
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 physician's services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic computed tomography (CT)
scan of the chest (71260).

You asked the Plan to waive the copayment for the CT scan. You say that you received a bill for $95 that
should have been sent to the Plan. The Plan denied your request. The Plan says that the $95 bill is for your
copayment for the service, which was billed and 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 up to a
$95 copayment for diagnostic radiology services (not including x-rays).

You have been asked to pay up to a $95 copayment for the CT scan. A CT scan falls within the diagnostic
radiology services (not including x-rays) 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 diagnostic computed tomography (CT) scan of the chest (71260).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy.

You asked the Plan to waive the copayment for physical therapy. You say that you were informed the
copayment would be $10 per session but you were billed $40 per session. You say that the Plan made an error.
The Plan denied your request. The Plan says the copayments 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 physical therapy at an in-network outpatient hospital.

You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is
$520 ($40/visit x 13 visits = $520). Physical therapy falls within the "Outpatient rehabilitation services" benefit
category. The records show the physical therapy was provided by the hospital. 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 physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit.

You asked the Plan to pay for office visit. You say that the provider told you that the Plan would cover this service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the payment information from your primary insurance carrier must be obtained before the Plan can process this 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 confirmed that this claim has been submitted to your primary insurance carrier at this time. As the secondary insurer, the Plan cannot be held responsible for office visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for an office visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office or other outpatient visit for the evaluation and management of a new patient (99204) to be rendered by the out of network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial as you require the expertise of the specialist requested. The Plan denied your request. The Plan says you must receive care from network providers. There are available contracted providers within the Plan that may render the service requested.
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 care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office or other outpatient visit for the evaluation and management of a new patient (99204) to be rendered by the out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay.

You asked the Plan to waive the copayment for the inpatient stay. You say that scans from the previous hospital could not be accessed to see what they did or did not do. You say that you are appealing the decision to not cover the medical stay. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $295 copayment per day, days 1 to 6 at an in-network inpatient hospital.

The enrollee has been asked to pay a $590 copayment for the inpatient stay. ($295/day x 2 days = $590). The inpatient stay falls within the "Inpatient hospital care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient post-stabilization services.

You asked the Plan to pay for the inpatient post-stabilization services. You say that the enrollee does not meet the Medicare criteria for post stabilization care. The Plan denied your request. The Plan says the provider failed to request authorization to provide post-stabilization care once the enrollee's emergency medical condition had stabilized.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.

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 inpatient post-stabilization services. Our physician reviewer found the enrollee is nonverbal, with trach, and Guillain-Barre syndrome (no vent) who was hospitalized with respiratory distress related to sepsis/UTI/HCAP/aspiration pneumonia. He was treated with antibiotics and bronchodilators as well as oxygen. The enrollee was significantly improved and stable, less secretions, and no acute distress. There was no documentation that the enrollee was not stable for transfer. The enrollee appeared to be stable for transfer.

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 inpatient post-stabilization services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient post-stabilization services.