Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network physical therapy.

You asked the Plan to pre-approve out-of-network physical therapy. You say that you were seen at this provider for a work injury, and the worker's comp provider will not facilitate any more visits. You say that you are still experiencing tremendous pain and you should be able to continue using this provider. The Plan denied your request. The Plan says the requested provider is out-of-network and in-network providers are 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 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 out-of-network physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99347), the trimming of skin lesions (11056), and the trimming of non-dystrophic nails (11719) rendered by an out-of-network (OON) provider on March 18, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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.

You are not a network provider with the Plan. The Plan had network providers available who could have provided 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 home visit for the evaluation and management of an established patient (99347), the trimming of skin lesions (11056), and the trimming of non-dystrophic nails (11719) rendered by an out-of-network (OON) provider on March 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location (R0075), the set-up of portable x-ray equipment (Q0092), the x-ray exam of the hand (73120), and the x-ray exam of the finger (73140) rendered by the out-of-network (OON) provider on May 21, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location (R0075), the set-up of portable x-ray equipment (Q0092), the x-ray exam of the hand (73120), and the x-ray exam of the finger (73140) rendered by the out-of-network (OON) provider on May 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) provider on August 20, 2021.
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 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 drug test (G0480) rendered by the out-of-network (OON) provider on August 20, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to provide coverage for the abutment supported porcelain/ceramic crown (D6058) provided July 19, 2021 with a $400 copayment.
You asked the Plan to provide coverage for the abutment supported crown. You say that the Plan covers crown and should cover this service. The Plan denied your request. The Plan says that this service is not covered under your benefits.
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 crowns once every 60 months with a $400 copayment. We looked at your contract with the Plan. We did not see where the contract says that only specific crowns are covered under your benefits. The Plan contract does not clearly say abutment supported crowns are not covered. Based on this information, we decided that the Plan's rules for coverage of the abutment supported crown have been met. Therefore, we decided that the Plan has to provide coverage for the abutment supported porcelain/ceramic crown (D6058) provided July 19, 2021 with a $400 copayment.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure.
You asked the Plan to pre-approve a Vertiflex procedure. You say that the services are 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. 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 a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertilfex device is experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88305, 88309, 88313, 88341, 88342, 88360) provided on June 16, 2021.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). A physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the enrollee was an inpatient at the time of service. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (88305, 88309, 88313, 88341, 88342, 88360) provided on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81407, 81408) provided April 28, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 

We looked at the file and Medicare rules. The record does not show that the service was ordered by the physician treating the enrollee. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81407, 81408) provided April 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says evidence for the benefit of this technology is insufficient or unproven.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental and investigational at this time. Therefore, the request is deemed not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on August 16, 2021.

You asked the Plan to waive the copayment for laboratory services. You say that you feel that the charges are too high and the Plan should be paying more. 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 $20 copayment for laboratory services. 

You have been asked to pay a $20 copayment for laboratory services. Laboratory services 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 copayment for laboratory services provided on August 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services (97530) provided on September 2, 2020.

You asked the Plan to pay for the therapy 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 as billed.

The Plan must follow Medicare rules. Medicare rules say that the services of a OTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services.

Therefore, we decided that the Plan does not have to pay for the therapy services (97530) provided on September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair and accessories for the enrollee.

You asked the Plan to pre-approve a manual wheelchair and accessories. You say that a manual wheelchair and accessories is medically necessary. The Plan denied your request. The Plan says Medicare does not cover durable medical equipment for skilled nursing facility (SNF) residents. The Plan suggests if the enrollee is eligible for Medicaid the request should be submitted to that agency.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. The records show that a manual wheelchair and accessories is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair and accessories for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services received from December 15, 2020, to January 26, 2021.
You asked the Plan to pay for the services. You say that these health aid services are covered by your insurance policy. The Plan denied your request. The Plan says the benefit for home health care is for services rendered by a home health care agency and is only covered part-time or intermittent.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. This would only be covered if it was rendered by an official home health care agency. There is no evidence that you are under the care of a physician or allowed practitioner. 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 home health services received from December 15, 2020, to January 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from March 26, 2021, to March 31, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you were not informed that the pharmacy at the hospital was not part of your network. You say that you were not told this. You say that you were told not to bring any of your daily medications. You also say that you do not have money to pay this bill. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan
says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under 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 pay for the self-administered drugs provided in an outpatient setting from March 26, 2021, to March 31, 2021.
Benefits for the self-administered drugs 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 waive the copayment for the specialist visit provided during your outpatient observation stay on August 23, 2021.
You asked the Plan to waive the copayment for the specialist visit provided during your outpatient observation stay. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a specialist visit during your outpatient observation stay on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each specialist visit.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a specialist visit during your outpatient observation stay on August 23, 2021. You have been asked to pay a $35 copayment for the specialist visit provided during your outpatient observation stay. The specialist visit provided during your outpatient observation stay falls within the Physician/Practitioner 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 specialist visit provided during your outpatient observation stay on August 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus (COVID-19) test provided September 10, 2021.
You asked the Plan to pay for the COVID-19 test. You say that you would like reimbursement for the test. The Plan denied your request. The Plan says this provider is not contracted with Medicare and therefore the service is not covered.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the coronavirus (COVID-19) test provided September 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88112) provided on August 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab services. You say that this lab processes tests and specimens submitted by other providers. The enrollee does not come to the lab and it is the responsibility of the doctor's offices to request prior authorization for services. The Plan denied your request. The Plan says the enrollee's contract with the Plan states that the Plan only has to pay for care from out-of-network providers 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 services in this case were not urgent or emergent, approved in advanced, or referred by a network provider. Therefore, these services are denied.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for lab services (88112) provided on August 23, 2021 by an out-of-network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on June 22, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the evaluation and management service. You say that the services were rendered to the enrollee in good faith. The Plan denied your request. The Plan says prior authorization was not obtained before the service was rendered to the enrollee. The Plan says that the service rendered was not urgent or emergent in nature. The Plan also says that the service could have been provided in network.
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 referring provider is not a network provider either. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on June 22, 2021, 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 rendered by the out-of-network (OON) provider on April 30, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 laboratory services rendered by the out-of-network (OON) provider on
April 30, 2021