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

We decided that the Plan does not have to pay for the special pump services rendered on
December 18, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are
statutorily excluded.
The provider submitted a claim for procedure code 99190 (special pump services). This code has a status
indicator of X and no separate Medicare payment. Payment is included in the payment to the facility Therefore,
we decided that the Plan does not have to pay for the special pump services rendered on
December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on November 7, 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 November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe vision care services provided on December 9, 2019 by an out-of-network provider.You asked the Plan to waive the copayment forthe vision care services. You say that you were not aware of a charge at the time of service as the provider did not charger you anything when the exam took place.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). The Plan approved the refraction services provided by your doctor per your plan's EOC. According to the 2019 EOC for the Diamond Plan on page 114 the benefit states that for each Medicare covered Glaucoma screening we will cover 50% of the Medicare Allowable for out-of-network providers. The Plan will not cover your eye exam copay because per your EOC for eye exams you have a $30 copay in or out of network. 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 forthe vision care services provided on December 9, 2019 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee from November 19, 2019 through December 9, 2019.You asked the Plan to pay forinpatient mental health care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any behavioral issues as he was described as being calm. It did not appear medically necessary and reasonable to have psychiatriccare provided at the acute inpatient level of care rather than a lower level of care as he did not have dangerousness to self or others, perceptual disturbance including auditory or visual hallucinations. The health plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. I am unable to find an individualized treatment plan however the entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of November 19, 2019 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee from November 19, 2019 through December 9, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on December 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician 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 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 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 physician services provided on December 19, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran office visit on October 22, 2019.You asked the Plan to waive the copayment foran office visit. You say that this was your annual wellness visit and should not be responsible for 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for primary care provider visits. You had an office visit on October 22, 2019. The record shows that you had an annual wellness visit on September 18, 2019. Only one annual wellness visit is covered without a copayment per year. Therefore, you are responsibleto pay the $10 copayment. You have been asked to pay a $10 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay thecorrect 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 foran office visit on October22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora screening mammogram (77067) provided October 23, 2019 by provider.You asked the Plan to pay forthe mammogram. You say that the mammogram should be covered.The Plandenied your request. The Plan says services provided out-of-network are now subject to a deductible.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 out-of-network services. The item or service you asked the Plan to pay for falls within the benefit category out-of-network services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750deductible for out-of-network services. The deductible had not been met at the time the mammogram was provided. The mammogram was provided out-of-network. This means the deductible was correctly applied. This cost sharing is a contractual obligation that had not been met at the time the mammogram was received on October 23, 2019.Therefore, we decided that the Plan does not have to pay fora screening mammogram (77067) provided October 23, 2019 by enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveXiidra eye drops.You asked the Plan to pre-approveXiidra eye drops. You say that this medication has worked for the enrollee in the past.The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveXiidra eye drops.Benefitsfor Xiidra eye dropsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses provided to the enrollee on September 28, 2019 by an out-of-network provider.
You asked the Plan to pay for the eyeglasses. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says this is not covered by the medical plan if the enrollee has vision coverage the provider should submit to that vision plan for coverage determination.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. If you look on page 82 and 85 of the members EOC, it states that the member has coverage with the plan for medical diagnosis and treatment of disease and injury of the eye on page 82. If you look at the vision coverage, it states that the member has coverage for a vision exam, this does not include the glasses itself, only the vision exam, on page 85. Therefore, we decided that the Plan does not have to pay for the eyeglasses provided to the enrollee on September 28, 2019 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for travel and lodging expenses from March 10, 2019 to October
27, 2019.
You asked the Plan to pay for travel and lodging expenses. You say that you had a kidney transplant on
September 7, 2017 and drive to the transplant clinic for tests and appointments. You also visit your
kidney donor and request to be compensated for costs. The Plan denied your request. The Plan says members
have 1 year to from the day of transplant to submit claims for travel reimbursement consideration. You were
eligible for the travel and lodging benefit until September 7, 2018.
The Plan must follow Medicare rules. The health plan has rules that exceeds Medicare. The plan's Transplant
Travel Reimbursement Guidelines say covered transplant travel services include costs to and from the hospital
or doctor's office for evaluations, second opinions, transplant services and follow-up care. Gas is considered a
non-covered item. You have up to one year (365 days), from the day of your transplant, to send transplant
travel reimbursement claims for payment consideration.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of travel and lodging expenses have not been met. Therefore, we decided that the Plan does not have
to pay for travel and lodging expenses from March 10, 2019 to October 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided to the enrollee on May 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the procedure codes do not need authorization. The Plan denied your request. The Plan says there is no valid referral for the 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 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 OON services. Therefore, we decided that the Plan does not have to pay for the vision services provided to the enrollee on May 2, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an observation stay, a CT scan and an MRI provided from July 14, 2019 to July 17, 2019.
You asked the Plan to waive the copayments for an observation stay, a CT scan and an MRI. You say that you were told that you would only owe a $150 copayment. 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 $150 copayment for each outpatient hospital stay. Your contract with the Plan also clearly says that you must pay a $115 copayment for each diagnostic radiology service. You had an observation stay, a CT scan and an MRI from July 14, 2019 to July 17, 2019. Therefore, you are responsible to pay a $150 copayment for the outpatient hospital stay and a $115 copayment per each diagnostic radiology service. The total amount you owe is: $380. You have been asked to pay the total copayment amount of $380 for an observation stay, a CT scan and an MRI. An observation stay falls within the outpatient hospital services benefit category. A CT scan and an 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 copayments for an observation stay, a CT scan and an MRI provided from July 14, 2019 to July 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper dentures (D5110) and complete lower dentures (D5120).
You asked the Plan to pre-approve complete upper dentures and complete lower dentures. You say that you do not have dentures at this time since the provider did not complete the job. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria has not been met.
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 complete dentures (upper and lower) once every five years. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of complete upper dentures and complete lower dentures have not been met. The record shows that you received complete upper and lower dentures on November 5, 2019. This means that you are not eligible for health plan coverage of complete upper dentures and complete lower dentures at this time. Therefore, we decided that the Plan does not have to pre-approve complete upper dentures (D5110) and complete lower dentures (D5120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forCystatin C testing provided on November 6, 2019.You asked the Plan to pay forlab test. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a physician order or clear intent to order this specific lab test.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order this specific lab test. Based on this information, we decided that Medicare rules for coverage of lab test have not been met.Therefore, we decided that the Plan does not have to pay forCystatin C testing provided on November 6, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vestibuloplasty to prevent further infections from dental implants.You asked the Plan to pre-approve the vestibuloplasty. You say that you have been diagnosed with receding gum line which needs grafting performed to prevent infections.The Plan denied your request. The Plan says this is a dental procedure and is not covered by Medicare.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care and treatment of 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 pre-approve a vestibuloplasty to prevent further infections from dental implants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assistant to surgery services provided on July 30, 2019.You asked the Plan to pay forthe assistant to surgery 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.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 31575. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the assistant to surgery services have not been met.Therefore, we decided that the Plan does not have to pay forthe assistant to surgery services provided on July 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean additional unit of Breast Cancer Index testing provided to the enrollee on July 25, 2019.You asked the Planto pre-approvethe testing. You say that this should be paid for.The Plandenied your request. The Plansaysthis is only covered once per lifetime.The Plan must follow Medicare rules. Medicare rules say that BCI testing is covered once per lifetime.The testing was requested twice for one specimen. It can only be approved once. The second unit of testing is not covered. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean additional unit of Breast Cancer Index testing provided to the enrollee on July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered to enrollee on December 12, 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 the services are not covered.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay for the special pump services rendered to enrollee on December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on April 8, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on April 8, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90834) provided on November 13, 2019.
You asked the Plan to pay for the mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or pre-authorized. 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 psychotherapy services (90834) provided on November 13, 2019.