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

We decided that the Plan does not have to pay for the dental services provided on January 17, 2020 by an OON provider.
You asked the Plan to pay for the dental services. You say that the services should be paid for by the Plan because you were not aware that the provider was OON. You also say that the provider did not inform you that they do not accept your plan. The Plan denied your request. The Plan says the services were rendered by a non-participating provider.
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 OON. Therefore, we decided that the Plan does not have to pay for the dental services provided on January 17, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a consultation provided received on March 3, 2020.
You asked the Plan to pay for the services. You say that the provider would not administer the shot without having the consultation for reducing the risks. The Plan denied your request. The Plan says this is an out-of-network provider.
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 rendering 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 a consultation received on on March 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on January 30, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency 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 networkproviders available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

Explanation of decision
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99337) provided by the out of network (OON) provider on March 11, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was provided by an out of network 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99337) provided by the out of network (OON) provider on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on December 31, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be responsible for the copayment because your visit was only 3 minutes long and you were told you needed a CT scan. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $50 copayment for specialty physician. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows that you were seen for a neurosurgical spinal consultation.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit provided on December 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrodesis services (CPT 22630) provided to the enrollee on May 13, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says CPT 22630 is not supported by the medical records submitted, as the operative report did not contain documentation of the service rendered.
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 22630 is "a single lumbar interspace arthrodesis using a posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression)." We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the medical records provided do not include documentation of an 22630 - Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar being performed on May 13, 2019, therefore this service cannot be verified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for arthrodesis services (CPT 22630) provided to the enrollee on May 13, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you fortravel and lodging expenses for travel to a non-approved transplant facility from January 13, to January 17, 2020.You asked the Plan to reimburse you fortravel and lodging expenses. You say that you had to see your oncologist so the Plan should reimburse you.The Plan denied your request. The Plan says services were not at your assigned facility.The Plan must follow Medicare rules. Medicare rules say that travel and lodging expenses are provided to a Medicare-approved transplant center.We looked at the file and Medicare rules. These expenses were not to the approved facility. 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 reimburse you fortravel and lodging expenses for travel to a non-approved transplant facilityfrom January 13, to January 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral medications provided from January 17, 2020 to January 18, 2020.
You asked the Plan to pay for the oral medications. You say that you have a very limited income. You also say that you cannot afford over $900 for the drugs. The Plan denied your request. The Plan says oral medications are considered "self-administered". The Plan says self-administered drugs are not covered under your Medicare Part B coverage.
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 pay for the oral medications provided from January 17, 2020 to January 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 4, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 to the enrollee by an out-of-network provider on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on January 23, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 to you by an out-of-network provider on January 23, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 6, 2020 through January 10, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 6, 2020 through January 10, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.You asked the Plan to pre-approve Euflexxa. You say that the request for Euflexxa is medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc AND Monovisc first.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 Euflexxa. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of Unilateral primary osteoarthritis of the right knee. The Plan requires a trial of Orthovisc AND Monovisc first before they will approve the requested drug, Euflexxa. The case file does not contain documentation of trial and failure of Orthovisc and Monovisc. The documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met.Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the intravitreal injections provided on June 11, 2019 and October 22, 2019.
You asked the Plan to waive the copayment for the intravitreal injections. You say that you had the injections done at an eye clinic and not a surgical center. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $295 copayment. for each Medicare-covered outpatient procedure in a hospital or ambulatory surgical center (ASC). You have been asked to pay a $295 copayment for each of the intravitreal injections. The intravitreal injections falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by an outpatient hospital.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the intravitreal injections provided on June 11, 2019 and October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the resin based composites (D2391) for teeth # 4 and 5 provided on April 9, 2019.
You asked the Plan to reimburse you for the dental services. You say that the provider's office did not inform you that the services would not be covered. The Plan denied your request. The Plan says the resin based composites that you received are not covered for the tooth surface that they were provided.
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 and resin based composites are listed as a covered service, the surfaces on which the composites were placed are not covered. The Evidence of Coverage clearly states that resin based composites are only covered for the buccal surface on posterior teeth. Therefore, we decided that the Plan does not have to reimburse you for the resin based composites (D2391) for teeth # 4 and 5 provided on April 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an Inogen One G3 Portable Oxygen System purchased on February 25, 2019.
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that your portable tanks only last about two hours and you reviewed the market for the best price on the portable oxygen concentrator. The Plan denied your request. The Plan says only rented oxygen equipment is eligible for coverage.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage. We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to reimburse you for an Inogen One G3 Portable Oxygen System purchased on February 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement prosthesis and accessories to be provided by an out of network provider.
You asked the Plan to pre-approve a replacement prosthesis and accessories. You say that you wish to receive your next prosthesis from the out of network provider. The Plan denied your request. The Plan says they have in-network providers within a reasonable distance from your location that can provide this service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a replacement prosthesis and accessories to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the meningococcal vaccine provided to the enrollee on January 7, 2020.
You asked the Plan to pay for the vaccine. You say that this vaccine was ordered prior to your surgery. The Plan denied your request. The Plan says this type of vaccine is not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that that the enrollee had been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the meningococcal vaccine provided to the enrollee on January 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jardiance for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee has done well on samples of this medication. The Plan denied your request. The Plan says that this medication is not covered under Part B.
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-approve Jardiance for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on December 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
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 to the enrollee by an out-of-network provider
on December 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 31, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says the member's primary care physician did
not refer these services. The Plan says that 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 physician services provided on January 31, 2020
by an out of network (OON) provider.