Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not have to pay forphysician services provided to the enrollee from August 9, 2019 to August 14, 2019.You asked the Plan to pay forthis claim. You say that this claim should be paid.The Plan denied your request. The Plan says the ordering physician was not a plan provider and the enrollee did not have prior authorization for 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 forphysician services provided to the enrollee from August 9, 2019 to August 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Spiriva inhaler.
You asked the Plan to pre-approve the Spiriva inhaler. You say that this is necessary to treat the enrollee's lung disease. The Plan denied your request. The Plan says this is a self-administered drug which is not covered by Medicare 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 a Spiriva inhaler.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on September 5, 2019.You asked the Plan to pay for the orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on September5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forservices provided to the enrollee on February 5, 2019 and billed under code28120.You asked the Plan to pay for these services. You say that this claim should be paid.The Plan denied your request. The Plan says while code 15275 will be paid, Current Procedural Terminology (CPT) code 2812058 remains not supported. The documentation submitted did not include documentation of a partial excision. The billed code cannot be verified. The Plan states that multiple attempts were madeto contact the provider for additional information. The Plan has insufficient documentation to corroborate the services provided. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT codeand provide medical records to support the services billed. The records provided with the claim do not support all of the services billed. We note the Plan indicates attempts have been made to work with the providerto submit new information or a corrected claim. The Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay forservices provided to the enrollee on February 5, 2019 and billed under codes 28120
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), and the bitewing x-rays (D0274) provided on October 8, 2019.
You asked the Plan to pay for the dental services. You say that you cannot afford to pay the fees for the services that you received. You also say that you are disabled. The Plan denied your request. The Plan says the periodic oral evaluation and bitewing x-rays are not listed as covered services.
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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), and the bitewing x-rays (D0274) provided on October 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora cataract surgery provided on October 8, 2019.You asked the Plan to waive the copayment fora cataract surgery. You say that you disagree with the high copay 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 $300 copayment for outpatient surgery services provided in an ambulatory surgical center. You have been asked to pay a $300 copayment for a cataract surgery. A cataract surgery falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora cataract surgery provided on October 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient behavioral health admission for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says a full mental health assessment was not available for review.
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 pre-approve the admission. Our reviewer says that
the requested admission is not medically reasonable or necessary. Our physician reviewer found based upon a
review of the records provided, admission of this enrollee does not meet the criteria for acute inpatient mental
health treatment as this patient was not shown to be a danger to himself or others but was without any abnormal
behaviors, without perceptual disturbance including auditory or visual hallucinations.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve an inpatient behavioral health admission for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy evaluation provided on August 23, 2019.You asked the Plan to waive the copayment for the physical therapy evaluation. You say that you were informed physical therapy would help. You say that you were advised your copayment would be $5.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 $20 copayment at all locations of service for outpatient rehabilitation services.You have been asked to pay a $20 copayment for the physical therapy evaluation. The physical therapy evaluation falls 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 the physical therapy evaluation provided on August 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHydralazine tablets.You asked the Plan to pre-approveHydralazine. The Plandenied your request. The Plan says Hydralazine to be administered at home is not covered under the Part B benefit.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-approveHydralazine tablets.Benefits for Hydralazinemay 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 5, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider 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 laboratory services provided on October 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray and consultation provided on July 18, 2019.
You asked the Plan to pay for the panoramic x-ray and consultation. You say that you did not request or receive dental coverage. You also say that the Plan told you these services were covered and referred you to this provider. The Plan denied your request. The Plan says the services received are not covered by Medicare. The Plan also says that they confirmed that you did not contact the customer service department to verify your benefits prior to receiving the services.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for 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 pay for the panoramic x-ray and consultation provided on July 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on
June 20, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis
(L3916) provided to the enrollee on June 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 19, 2018 by an out-of-network provider.
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 were rendered 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 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 November 19, 2018 by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 71045) provided to the enrollee on September 25, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate claim line.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The records provided show that the services in question were billed on a duplicate claim line as one already paid by the plan for the same date of service. 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 the services (CPT 71045) provided to the enrollee on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar/sacral facet joint radiofrequency neurolysis.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found sacroiliac joint radiofrequency ablation is not a covered benefit. Radiofrequency facet joint denervation of spinal nerves in the treatment of sacroiliac joint pain is considered experimental/investigational. The safety and/or effectiveness of this procedure cannot be established by review of the available published peer-reviewed literature. Larger, well-designed trials are needed for comparing specific procedures in defined populations for use in sacroiliac pain and to determine the potential candidates and treatment parameters for this disorder. It is considered experimental/investigational. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar/sacral facet joint radiofrequency neurolysis.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 28, 2019 to August 30, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says custodial services or supplies are not covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 pay for the skilled nursing services provided from August 28, 2019 to August 30, 2019. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found that the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 28, 2019 to August 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to enrollee by an out-of-network provider on February 13, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.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 enrollee by an out-of-network provider on February 13, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan 500mg/50ml infusion.You asked the Plan to pre-approve Rituxan 500mg/50ml infusion. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Rituxan 500mg/50ml infusion. Our reviewer says that the medication is not medically necessary. Our physician reviewer found review of compendia does not support the use of Rituxan for this diagnosis. It is noted to have inconsistent study results and additional research is indicated. Without the support of the literature, the use is not considered safe and effective.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan 500mg/50ml infusion have not been met.Therefore, we decided that the Plan does not have to pre-approveRituxan 500mg/50ml infusion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for MOHS surgery provided out of network on June 3, 2019.
You asked the Plan to pay for out of network providers. You say that this surgery should be covered by the Plan. The Plan denied your request. The Plan says this surgery was ordered by an out of network provider to be performed out of network 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 must 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 MOHS surgery provided out of network on June 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment and balance billing for the ambulance
transportation services you received on January 5, 2019.
You asked the Plan to waive the charges. You say that you are being balance billed by the provider. The Plan
denied your request. The Plan says you are responsible for the cost share.
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 $195
copayment for each one-way Medicare-covered ground ambulance trip.
Review of the file shows that you were provided ground ambulance transportation on January 5, 2019. You
have been asked to pay a $195 copayment for the services. The services fall within the ambulance 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. Please
note that you are not liable for any amount greater than this copayment. Medicare rules do not allow noncontract
providers to balance bill enrollees of a Medicare health plan. Therefore, we decided that the Plan does
not have to waive the copayment and balance billing for the ambulance transportation services you received on
January 5, 2019.