Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on November 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the vision services. You say that the services were rendered to the enrollee while they were in a contracted skilled nursing facility (SNF). The Plan denied your request. The Plan says prior authorization was not obtained prior to the services being rendered. The Plan says that the enrollee was in long term care at the contract facility at the time the services were rendered. The Plan says that long term care services are not covered by Medicare. The Plan also says that the out of network provider would be responsible for securing the 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 provider in this case is not a network provider with the Plan. 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 November 17, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided November 19, 2020.
You asked the Plan to pay for the dental cleaning. You say that you have always had the same dentist and did
not know the service would not be covered. The Plan denied your request. The Plan says the services were
provided by an OON provider and therefore are not covered.
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. The Plan covers the dental
cleaning when the services are provided in-network.
We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the
Plan at the time of the service. 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. Based on this information, we decided
that the Plan's rules for coverage of the dental cleaning have not been met. Therefore, we decided that the Plan
does not have to pay for the prophylaxis (D1110) provided November 19, 2020.
Your complaint about the network status of your provider is not a valid appeal for medical coverage. This part
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion visit (99601) provided on August 20,
2020.
You asked the Plan to pay for the home infusion visit. The Plan denied your request. The Plan says the denial
of payment for these services is correct, because the billed code is not valid for Medicare purposes and is not
covered.
The Plan must follow Medicare rules. Medicare rules say that procedure code 99601 is not valid for Medicare
purposes and is not payable.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home infusion visit have not been met. Therefore, we decided that the Plan does not have to
pay for the home infusion visit (99601) provided on August 20, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for behavioral health services provided on January 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for behavioral health services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says these services were provided by an out-of-network provider. The Plan says that the member's primary care physician did not refer 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 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 behavioral health services provided on January 6, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on August 14, 2020.
You asked the Plan to pay for the PET scan. The Plan denied your request. The Plan says the PET scan was not billed with an appropriate diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis codes that may be used. We looked at the file and Medicare rules. In this case, the PET scan was not billed with an appropriate PET oncologic imaging diagnosis code. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on August 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, panoramic x-ray, preventive procedure, and two extractions provided on December 10, 2020.
You asked the Plan to pay for the first intraoral periapical x-ray, panoramic x-ray, preventive procedure, and extractions. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services are not covered.
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 first intraoral periapical x-ray, panoramic x-ray, preventive procedure, and two extractions provided on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the lodging services (S9975) provided from November 3, 2020, to November 19, 2020.
You asked the Plan to pay for the lodging services. The Plan denied your request. The Plan says the services were provided outside of the transplant date range.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code S9975 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Additionally, the lodging services were not provided with the date range of the transplant procedure. Based on this information, we decided that Medicare rules for coverage of the lodging services have not been met. Therefore, we decided that the Plan does not have to pay for the lodging services (S9975) provided from November 3, 2020, to November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue-soft (D7286) provided December 23, 2020.
You asked the Plan to pay for the biopsy. You say that the service was medically necessary and should be covered. The Plan denied your request. The Plan says the service is 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 pay for the incisional biopsy of oral tissue-soft (D7286) provided December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from July 21, 2020, to November 4, 2020.
You asked the Plan to pay for the dental services. You say that you were not aware that these providers had opted out of Medicare, and believe the services should be covered. The Plan denied your request. The Plan says these services were rendered by providers who have opted out of Medicare. The Plan also says that services performed by a privately contracted provider are not covered.
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 by a Medicare opt out provider. Therefore, we decided that the Plan does not have to pay for the dental services provided from July 21, 2020, to November 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says this item is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. 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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the brief emotional and behavior assessment and domiciliary or rest home visit provided on November 18, 2020 by an OON provider.
You asked the Plan to pay for the brief emotional and behavior assessment and domiciliary or rest home visit. You say that the services provided were medically necessary. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that prior authorization was not 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 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 the brief emotional and behavior assessment and domiciliary or rest home visit provided on November 18, 2020 by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided on October 2, 2020.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you were told that all copayments were waived due to COVID-19. 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 you must pay a $40 copayment for outpatient rehabilitation services. You received outpatient rehabilitation services on October 2, 2020. Outpatient rehabilitation services are not included in the COVID-19 copayment waiver. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided on October 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the goal is to allow the enrollee a
maximum opportunity of recovery. The Plan denied your request. The Plan says the enrollee's medical needs
are being met in the current acute setting.
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 physician
reviewer found that the enrollee was admitted to the acute care hospital with a self-inflicted gunshot wound to
the head, acute respiratory failure, and intracranial hemorrhage. The enrollee is receiving appropriate care at the
present acute care hospital. She does not require services at the LTACH that are not available at the acute care
hospital where she is currently receiving care. There are no services available at the LTACH that she requires
that are not available at the health care setting being offered by the health plan. Therefore, the requested
LTACH services are 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on August 11, 2020 by an
out of network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network
care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 the physician services provided on August 11,
2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approveneuropsychological testing to be provided by an out-of-network provider.You asked the Plan to pre-approvethe neuropsychological testing. You say that you switched insurance companies to keep your father with his primary care doctors and memory clinic. You say that you want to finish testing andassessments required to get a diagnosis.The Plan denied your request. The Plan says care must be received from a network provider.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providersavailable to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for 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 neuropsychological testing. Our reviewer says that the Plan has in-network specialists for this service. Our physician reviewer found that testing can be completed independently of the member's ongoing neurology evaluation since neuropsychological testing uses standardized testing/scales. 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 neuropsychological testing have not been met. Therefore, we decided that the Plan does not have to pre-approveneuropsychological testing with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the therapeutic radiology services and the specialist services provided on October 28, 2020.
You asked the Plan to waive the copayments for the therapeutic radiology services and the specialist services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received therapeutic radiology services and services provided by a specialist on the date of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.
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 $60 copayment for Outpatient diagnostic tests and Therapeutic Services and a $50 copayment for services obtained from a specialist. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received therapeutic radiology services and services provided by a specialist on October 28, 2020. You have been asked to pay a $60 copayment for therapeutic radiology services. The therapeutic radiology services fall within the Outpatient diagnostic tests and Therapeutic Services benefit category. You have also been asked to pay a $44.26 copayment for services provided by a specialist, which is less than the contracted $50 copayment amount. The services provided by a specialist fall within the Physician/Practitioner services benefit category. This means that you have been asked to pay the correct amounts 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 the therapeutic radiology services and the specialist services provided on October 28, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay forthe Cystourethroscopy described by current procedural terminology (CPT) code 52235 provided on September 14, 2020.You asked the Plan to pay forCPT code 52235. You say that the medical records support the billing of CPT code 52235 provided on September 14, 2020.The Plan denied your request. The Plan says that the medicalrecords do not support the billing of CPT code 52235 provided on September 14, 2020.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 52235 is Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm).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 CPT code 52235. Our reviewers says that the medical records support the billing of CPT code 52235 provided on September 14, 2020.Our physician reviewer found CPT code 52235 is the correct code for the procedure performed on 9/14/20. The surgeon resected a medium sized tumor from the prostatic urethra. This CPT code includes both bladder and urethral tumor resections.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 52235 have been met.Therefore, we decided that the Plan has to pay forthe Cystourethroscopy described by currentprocedural terminology (CPT) code 52235 provided on September 14, 2020.