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

We decided that the Plan does not have to pay for the anesthesia services provided to the enrollee on August 13, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the primary carrier needs to be billed first.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the plan as the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided to the enrollee on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on October 10, 2019.
You asked the Plan to waive the copayment for the eye exam. You say that you went in for a yearly eye check. You say that a routine eye exam has a $0 copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye. You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show that this was a medical eye exam. 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 eye exam provided on October 10, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve acupuncture treatment (97810, 97811).
You asked the Plan to pre-approve these services. You say that the enrollee has a diagnosis of peripheral neuropathy and neuropathic pain as well as multiple musculoskeletal and orthopedic diagnoses and contribute to daily pain, limitations of function, and reduced quality of life. The Plan denied your request. The Plan says that acupuncture is a non-covered benefit.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90 period, and no more than 20 sessions per year. 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 these services. Our reviewer says that the enrollee meets criteria for coverage of acupuncture treatment. Our physician reviewer found that the review indicates that the enrollee has a diagnosis of peripheral neuropathy and neuropathic pain as well as multiple musculoskeletal and orthopedic diagnoses that contribute to daily pain, limitations of function, and reduced quality of life. The documentation indicates that the enrollee has undergone treatment with medical therapy, physical therapy, injections and previous acupuncture treatment. He receives acupuncture treatments two or three times a month, as these have helped provide temporary relief in the past. Therefore, the review has determined that the documentation provided did determine that the enrollee meets criteria for coverage of acupuncture treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve acupuncture treatment (97810, 97811).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multi-level lumbar fusion for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your
request. The Plan says there must be images that show an unstable spine, and there must be notes showing at
least six weeks of conservative care, including injections and/or physical therapy.
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 surgery. Our reviewer says that the
requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no documentation of spinal instability, fracture, or lesion. Criteria for the multi-level fusion has
not been met.
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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve multi-level lumbar fusion for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation for dental implants.
You asked the Plan to pre-approve the dental consultation. You say that you would like reconsideration
because the dental implants are medically necessary. The Plan denied your request. The Plan says dental
implants are not a covered benefit under 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, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a consultation for
dental implants.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 25, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory 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 laboratory services provided on September 25, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 4, 2019 by an out of network (OON) provider. You asked the Plan to pay for the laboratory 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 laboratory services provided on November 4, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the FaceDown Recovery System purchased on June 20, 2019.
You asked the Plan to pay for the FaceDown Recovery System. You say that the Plan should reimburse you. The Plan denied your request. The Plan says that face-down positioning devices do not fall within a Medicare benefit category. 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 FaceDown Recovery System a contract provider. The file does not show that the Plan provided notice that the FaceDown Recovery System would not be covered. Under Medicare rules, this means the FaceDown Recovery System is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the FaceDown Recovery System purchased on June 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen equipment and hospital bed provided from May 1, 2019 to June 28, 2019, by an out of network provider,
You asked the Plan to pay for the oxygen equipment and hospital bed. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network provider 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 the oxygen equipment and hospital bed provided from May 1, 2019 to June 28, 2019, by an out of network provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on October 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that these lab tests were provided from a referring provider. The Plan denied your request. The Plan says the referring provider is out-of-network. 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 lab tests provided on October 14, 2019 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 three retainer crowns and three pontics provided on May 7, 2018 and October 23, 2019.
You asked the Plan to pay for the retainer crowns and pontics. You say that you had a chewing problem which affected your digestion process and correct feeding. You also say that these services were urgent and necessary. The Plan denied your request. The Plan says these services are 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 Plan only provides coverage for removable prosthodontia. The requested items or services are not covered because they are fixed prosthodontics. Therefore, we decided that the Plan does not have to pay for the three retainer crowns and three pontics provided on May 7, 2018 and October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chronic care management provided on July 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for chronic care management. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the rendering provider and facility are both out-of-network. 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 chronic care management provided on July 31, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from December 10, 2018 through December 18, 2018.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the member met their out-of-pocket maximum in September 2019. The Plan denied your request. The Plan says the out-of-pocket maximum for 2018 was not met and the total amount accumulated was $6,013.31 of $6,700.00.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that the enrollee was admitted on December 10, 2018 and discharged on December 18, 2018. The out-of-pocket maximum for 2018 was not met and the total amount accumulated was $6,013.31 of $6,700.00. The enrollee was asked to pay a $210 copayment per day from December 10, 2018 through December 15, 2018, days 1-6 of their inpatient stay. There were no copayment charges from December 16 2018, day 7 of their inpatient hospital care until their day of discharge December 18, 2018. Per the enrollee's contract there is a $210 copayment per day required for days 1-6. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from December 10, 2018 through December 18, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing rendered to the enrollee on October 11, 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 testing is not covered. The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479. The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 testing rendered to the enrollee on October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 23, 2019 and October 14, 2019.
You asked the Plan to pay for the physician's services. You say that you were not aware that the two doctors did not accept your insurance plan. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you received from an out-of-network provider will not be covered.
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 providers in this case are not network providers with the Plan. 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 physician's services provided on September 23, 2019 and October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 18, 2019 by an out of network (OON) provider. You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says utilization of network providers is required when possible and 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 medical services provided on September 18, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 11, 2019 by an out of network (OON) provider. You asked the Plan to pay for physician services. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says the rendering provider and facility are both out-of-network. 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 November 11, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 24, 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 there is no valid physician order. The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to the enrollee on April 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for physician services provided on February 22, 2019 and March 22, 2019. You asked the Plan to waive the coinsurance for physician services. You say that you consulted with the Plan before seeing this doctor. You say that you were informed you were covered. The Plan denied your request. The Plan says the coinsurance applied correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% of the Medicare-allowed amount for an out-of-network primary care provider visit for Medicare-covered services. You have been asked to pay a total of $133.04 for physician services. Physician services falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the provider is 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 coinsurance for physician services provided on February 22, 2019 and March 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on September 27, 2019.
You asked the Plan to pay for the periodontal maintenance. You say that you have your teeth cleaned 4 times per year. The Plan denied your request. The Plan says periodontal maintenance is not included in your dental benefit. The Plan also says this service is not considered a preventive dental service.
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 periodontal maintenance provided on September 27, 2019.