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 January 14, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says services from
non-participating providers are not covered unless they are 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 provided on January 14, 2020 by an out of network
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe anesthesia services you received on November 23, 2019.You asked the Plan to pay forthe anesthesia services. You say that because you are allergic to local anesthesia, you required surgery in a hospital.The Plan denied your request. The Plan says services in connectionwith the care and treatment of teeth are not covered.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe anesthesia services you received on November 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a resin-based composite (CPT D2393).
You asked the Plan to pre-approve the resin-based composite. You say that you were denied for a 3rd cavity seal and for special treatment resin based composite. You say that you are suffering from infection of your right tooth and are developing pus/blood in your gums. The Plan denied your request. The Plan says your benefit for fillings has been exhausted for the 2020 calendar 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, the benefit for fillings is limited to 2 per calendar year. The records show that the Plan already approved 2 fillings for you in the 2020 calendar year, under authorization number 171211539. This means that the filling you are requesting coverage for would exceed the benefit allowance for this type of service. Therefore, we decided that the Plan does not have to pre-approve a resin-based composite (CPT D2393).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient rehabilitation facility services provided from October 15, 2019 to October 28, 2019.You asked the Plan to pay for the inpatient rehabilitation facility services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. Medicare says IRFs are required to report billing data with revenue code 0024. The file shows the claim was billed without revenue code 0024.Therefore, we decided that the Plan does not have to pay for the inpatient rehabilitation facility services provided from October 15, 2019 to October 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 26, 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 on December 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and extraction provided by an out-of-network provider on March 4, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and extraction. You say that you could not get an endodontist that was in network within a month. You also say that you could not wait because you were in pain. The Plan denied your request. The Plan says you received services from a provider that does not participate in your plan's dental network. The Plan also says that you must use network providers to receive dental services.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and extraction provided by an out-of-network provider on March 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does nothave to pre-approvethe Aranesp.You asked the Plan to pre-approvethe Aranesp. The Plan denied your request. The Plan says they have approved the drug RETACRIT for three months. The Plan also says that the documentation does not support the Plan's medical necessity guidelines for coverage for Aranesp.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 the Aranesp. Our reviewer says that the Aranesp is not medically necessary. Our physician reviewer found the enrollee has not tried and failed the required drug, RETACRIT. Our reviewer found that thedocumentation does not support that RETACRIT (Epoetin alfa-epbx) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer also found that the enrollee has not had an inadequate responseto RETACRIT for at least two consecutive months.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hospital observation care (G0378, 99285) provided December 12 to December 13, 2019. You asked the Plan to waive the copayment for the observation care. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $250 copayment for observation services. You have been asked to pay a $250 copayment for the observation care. 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 hospital observation care (G0378, 99285) provided December 12 to December 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a participating provider on January 21, 2020.You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you stayed overnight. 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. You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total allowed amount is $9,258.59. The total amount you are being asked to pay is $1,851.72 ($9,258.59 x 20% = $1,851.72). Unless formally admitted to the hospital as an inpatient, an overnight stay can be billed as outpatient; therefore, the correct coinsurance has been applied. An outpatient surgery falls within the outpatient surgery 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 coinsurance for an outpatient surgery provided by a participating provider on January 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services (73610, 73501) provided on June 6, 2019 by an out of network (OON) provider.You asked the Plan to pay for the radiology services. You say that the services were medically necessary.The Plan denied your request. The Plan says services were not preauthorized or emergent. There were network providers available.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 radiology services (73610, 73501) provided on June 6, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on July 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services were self-referred.
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 psychotherapy provided on July 29, 2019 by an out of network (OON) provider.
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 the requested supplies have been covered for you previously. You say that you need the products because you have a constant bladder issue. You stated that you are on a fixed income and cannot afford them on your own. You say that you consider this a medical condition so the Plan should provide coverage. The Plan denied your request. The Plan says this item is not a covered benefit.
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 the services (CPT 99190) provided on September 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this services is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Dalbavancin injections (J0875) provided June 7, 2019.You asked the Plan to waive the coinsurance for the injections. You say that you were not informed of the coinsurance.The Plan denied your request. The Plan says the coinsurance is explained in the evidence of coverage.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 Part B drugs. You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Part B drugs 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 coinsurance for Dalbavancin injections (J0875) provided June 7, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a home health visit on January 3, 2020. You asked the Plan to waive the deductible for a home health visit. You say that you did not receive services because you did not feel good and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible for home health agency care. The medical records show that you had a home health visit on January 3, 2020. Therefore, you are responsible to pay your share of the cost-sharing charges. The record shows that you had paid $0 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $140.52. The item or service you asked the Plan to waive the deductible for falls within the benefit category home health agency care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for home health agency care. This cost sharing is a contractual obligation that had not been met at
the time a home health visit was received on January 3, 2020. Therefore, we decided that the Plan does not have to waive the deductible for a home health visit on January 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (E0652) and sleeves (E0667).You asked the Plan to pre-approve a pneumatic compression device and sleeves. You say that the enrollee has failed conservative treatment.The Plan denied your request. The Plan says that the enrollee has no truncal edema and did not fail a 4week trial of basic a lymphedema pump.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (E0652) and sleeves (E0667).
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay forthe electrocardiogram (EKG) interpretation rendered on July 8, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the claim is a duplicate.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 deny your request. The Plan states that the claim is a duplicate and that only one interpretation of an EKG is allowed per date of service; however, the Plan has not provided any documentation of a duplicate claim for the date of service at issue. There is no documentation to support that the claim is not payable as billed, per Medicare rules.Therefore, we decided that the Plan has to pay forthe electrocardiogram (EKG) interpretation rendered on July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the radiation therapy and MRI provided from July 16, 2019 through August 2, 2019.
You asked the Plan to waive the cost share for the radiation therapy and MRI. You say that the treatments should be considered part of the clinical trial. You say that the charges shouldn't be your responsibility. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each in-network visit for therapeutic radiology services and a $250 copayment for in-network advanced imaging services.
You have been asked to pay a total of $3,735.30 for radiation therapy and MRI.
Date of Service
Service
Provider
Allowed Amount
Standard Cost Share
Member Liability
July 16, 2019
Radiation Therapy
Physician
$352.58
20%
$70.51
July 16, 2019
Radiation Therapy
Hospital
$1,770.52
20%
$354.10
July 16, 2019
MRI
Hospital
$1,012.13
$250
$250
July 29, 2019
Radiation Therapy
Physician
$694.07
20%
$138.81
July 29, 2019
Radiation Therapy
Hospital
$2,210.62
20%
$442.12
July 31, 2019
Radiation Therapy
Physician
$42.24
20%
$8.45
July 31, 2019
Radiation Therapy
Physician
$726.90
20%
$34.63
July 31, 2019
Radiation Therapy
Hospital
$4,431.23
20%
$886.25
August 1, 2019
Radiation Therapy
Hospital
$3,771.06
20%
$754.21
August 2, 2019
Radiation Therapy
Hospital
$3,981.22
20%
$796.22
TOTAL:
$3,735.30
The radiation therapy and MRI fall 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 cost share for the radiation therapy and MRI provided from July 16, 2019 through August 2, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided to the enrollee on April 2, 2019.You asked the Plan to pay for the services. You say that as this was a therapy charge, a room and board code will not be on this claim.The Plan denied your request. The Plan says the service was billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We asked our coding 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. Ourreviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the claim was not billed appropriately, therefore cannot be considered for reimbursement. Room and board charges are required when billing to a Medicare Advantage Plan.We looked at this coder'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 forphysical therapy services provided to the enrollee on April 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 3, 2019 by a non-contracted provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-contracted 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 forthe medical services provided on September 3, 2019 by a non-contracted provider.