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

We decided that the Plan does not have to pay for laboratory services (80169, 80197, 87497, 87799) provided
on August 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab services. You say that the information sent details the patient's history and
symptoms that led to the physician requesting these services in order to evaluate and manage the patient's
condition. The Plan denied your request. The Plan says a member must obtain pre-authorization to a nonnetwork
provider if there are no network providers with the appropriate training and experience to meet the
member's particular health care needs.
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 record shows that the Plan's Medical
Director determined that this service could have been provided by a participating provider. 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 (80169, 80197, 87497, 87799) provided on August 29, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy (PT) (97140, 97530) provided on August 1, 2019 through August 9, 2019 by the out of network provider.
You asked the Plan to pay for PT. You say that you have been working through negotiations with the Plan for months. Your facility was unaware that authorizations were required during the negotiations. The Plan denied your request. The Plan says the rendering provider is a non-participating facility. The attending provider is a non-participating provider. We did not authorize any services for the facility nor the physician. There are multiple in-network providers within 30 miles of the members residence that could have rendered the services. The services are not considered urgent/emergent in nature.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physical therapy (PT) (97140, 97530) provided on August 1, 2019 through August 9, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 30, 2019 by the out of network provider.
You asked the Plan to pay for physician services. You say that the member provided you information for the Plan. You say that you did not know the member was covered by another Plan. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there are in-network providers available for these services.
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 physician services provided on March 30, 2019 by the out of network provider.
Appeal type: Hospice
Decision: Favorable

We decided that the Plan has to pay for a home health visit provided on August 21, 2019.
You asked the Plan to pay for the home health visit. You say that you did not realize The Plan was the enrollee's primary insurance and needed authorization. The Plan denied your request. The Plan says that Hospice is not a covered service by Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.
The 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 did not submit evidence that the enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan has to pay for a home health visit provided on August 21, 2019.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the hearing aid accessory (V5267)
You asked the Plan to issue reimbursement for the hearing aid accessory. You say that you are requesting a reconsideration of the Plan's denial for payment as the hearing aid tubes are an essential part of the hearing aids. The Plan denied your request. The Plan says that this service is a covered benefit under your contractual policy; however, you have exceeded the allowable benefit.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid accessory have not been met. Specifically, you have exceeded the allowable hearing aid benefit maximum as the Plan issued reimbursement to you in the amount of $1000 for the hearing aids purchased on this date of service. Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aid accessory (V5267
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a health club membership provided for 2017 and 2018.
You asked the Plan to reimburse you for the health club membership. The Plan denied your request. The Plan says reimbursement requests must be received by the Health Plan Medicare Preferred by no later than March 31st of the following year. It was determined that you did not submit your reimbursement request within the required time frame for your 2017 and 2018 Wellness Allowance.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because it was determined that you did not submit your reimbursement request within the required time frame for your 2017 and 2018 Wellness Allowance. Therefore, we decided that the Plan does not have to reimburse you for a health club membership provided for 2017 and 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for suspension sleeve (CPT Code L2397), knee control full kneecap (CPT Code L2795) and knee orthosis (CPT Code L1833) provided on July 16, 2019.
You asked the Plan to waive the coinsurance for the orthosis. You say that this may have been up coded so the provider would be reimbursed more than they should have been for the product. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). On July 16, 2019, you had received a knee orthosis. The medical records confirmed the correct codes (L1833, L2397, L2795) were billed with the claim Per your EOC, Prosthetic devices and related supplies apply a 20% coinsurance. This is a contractual obligation you agreed to when you enrolled with the Plan. This cost-sharing amount cannot be reduced or waived. Therefore, you will remain liable for the 20% coinsurance that applied to the knee orthosis on July 16, 2019. 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 suspension sleeve (CPT Code L2397), knee control full kneecap (CPT Code L2795) and knee orthosis (CPT Code L1833) provided on July 16, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the automatic external defibrillator garment provided on November 12, 2019.
You asked the Plan to pay for the device. You say that your cardiologist told you the device was approved and you accepted it. The Plan denied your request. The Plan says that you did not have prior authorization for the out-of-network service.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the device by your Physician. Your Physician is a contract provider. The file does not show that the Plan provided notice that the device would not be covered. Under Medicare rules, this means the device is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the automatic external defibrillator garment provided on November 12, 2019.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient psychotherapy sessions coded as 90832 (x20), 90834 (x5) and 90837 (x20) beginning January 9, 2020.
You asked the Plan to pre-approve the outpatient psychotherapy sessions. You say that you were under the impression that the rules and procedures from the one Plan would carry over to the other Plan and that authorizations would not be required for any of your services. The Plan denied your request. The Plan says the enrollee can be treated at an alternate level of care.
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 pre-approve the outpatient psychotherapy sessions. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on review the records provided, the requested sessions as noted, are excessive as symptomatology does not agree with medical necessity. The request for additional outpatient psychotherapy is not reasonable or medically necessary as this enrollee is not showing functional impairment in symptoms requiring additional therapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient psychotherapy sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve the outpatient psychotherapy sessions coded as 90832 (x20), 90834 (x5) and 90837 (x20) beginning January 9, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to reprocess payment at the Tier 1 benefit level for an upper gastrointestinal endoscopy provided on September 30, 2019 through November 11, 2019.
You asked the Plan to reprocess payment at the Tier 1 benefit level for the upper gastrointestinal endoscopy. You say that you were willing and eager to be treated by your Tier 1 provider, but they did not provide the service needed. The Plan denied your request. The Plan says that an approved authorization for Tier 1 benefit coverage needed to be obtained prior to receiving services in order for you to have Tier 1 coverage with this provider.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the upper gastrointestinal endoscopy by your Physician. Your Physician is a contract provider. You are not at fault when a contract provider does not adhere to Plan rules. Under Medicare rules, this means the upper gastrointestinal endoscopy is considered approved by the Plan. Therefore, we decided that the Plan has to reprocess payment at the Tier 1 benefit level for an upper gastrointestinal endoscopy provided on September 30, 2019 through November 11, 2019.
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 waive the copayment for outpatient observation services and outpatient rehabilitation services provided on September 23, 2019 to October 3, 2019.
You asked the Plan to waive the copayment for outpatient observation services and outpatient rehabilitation services. You say that you were an in-patient. You say that you spent the night in the hospital. The Plan denied your request. The Plan says the correct copayments have 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 $350 copayment for outpatient hospital services/the Plan and a $20 copayment for outpatient rehabilitation services/the Plan. You have been asked to pay a $350 copayment for outpatient observation service and a $20 copayment for outpatient rehabilitation services. Unless formally admitted to the hospital, overnight hospital stays are considered outpatient observation services. Outpatient observation services falls within the outpatient hospital services/the Plan and outpatient rehabilitation services falls within the outpatient rehabilitation services/the Plan 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 outpatient observation services and outpatient rehabilitation services provided on September 23, 2019 to October 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement provided from July 10, 2019 to October 30, 2019.
You asked the Plan to waive the copayments for wound debridement. You say that you did not receive services in an outpatient hospital facility. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that members must pay a $200 copayment for outpatient surgery services provided in an ambulatory surgical center and a $400 copayment for outpatient surgery services provided in an outpatient hospital facility. You received wound debridement at an outpatient hospital facility from July 10, 2019 to October 30, 2019. Therefore, you are responsible to pay the allowed amount of $1,838.12, which is less than the total copayment amount. You have been asked to pay $1,838.12 for wound debridement. Wound debridement 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 copayments for wound debridement provided from July 10, 2019 to October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 6, 2019 by the out of network provider.
You asked the Plan to pay for podiatry services. You say that if the doctor would have known the patient had Plan coverage, she would not have treated the patient. The Plan denied your request. The Plan says no prior authorization was obtained.
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 February 6, 2019 by the out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on January 23, 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 procedure code 92620 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 92620 is evaluation of central auditory function, with report; initial 60 minutes. We find that CPT code 92620 is not supported in the medical record. Specifically, there is no documentation that an evaluation of central auditory function for at least 60 minutes with report was performed. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on January 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on October 16, 2018 by the out of
network provider.
You asked the Plan to pay for the vision services. You say that even though the provider is not a Plan provider she is a Medicare provider and is willing to accept out of network payment. The Plan
denied your request. The Plan says enrollee's must receive their medical services from an in-network provider.
The plan says that non-emergent services with non-contracted providers require prior-authorization prior to
services being rendered.
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 vision services provided on October 16, 2018
by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, two additional intraoral periapical x-rays, extraction, and maxillary partial denture provided on September 18, 2019 and September 19, 2019.
You asked the Plan to pay for the intraoral periapical x-rays, extraction, and maxillary partial denture. You say that the tooth extraction was medically necessary. You also say that dentures were not a cosmetic procedure and would be covered under your plan according to your manual. The Plan denied your request. The Plan says based on your coverage, there is a $500 combined coverage limit each year for comprehensive and preventive covered supplemental dental care services. The Plan also says that you had reached this benefit limit.
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 Plan offers an annual benefit limit of $500 every year. The contract says that if the cost of the items exceeds the allowable amount of the Plan's Optional Supplemental Benefit, you are responsible for any additional costs. The record shows that you met the annual benefit limit on June 6, 2019 and your annual benefit limit was then exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray, two additional intraoral periapical x-rays, extraction, and maxillary partial denture provided on September 18, 2019 and September 19, 2019.