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

We decided that the Plan does not have to pay for the office visit received on January 28, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that this service was necessary for your surgery. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON 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 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 the office visit received on January 28, 2021 by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc-One injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says step therapy guidelines were not followed.

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 the injection. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the provided records do
not indicate that the enrollee has tried and failed the plan's preferred step one alternatives. The record does not
indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred
step one alternatives. The elements of the coverage criteria are not satisfied.

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 a Synvisc-One injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the manual wheelchair you rented from March 12, 2020, to February 12, 2021.

You asked the Plan to waive the coinsurance for the wheelchair rental. You say that no one ever told you this was a rental and you don't understand why you are still getting billed. The Plan denied your request. The Plan says you were charged this coinsurance correctly as this item is a monthly rental.

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 20% coinsurance for durable medical equipment. 

You have been asked to pay 20% coinsurance for the wheelchair rental. The wheelchair rental falls within the durable medical equipment 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 coinsurance for the manual wheelchair you rented from March 12, 2020, to February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit received on March 15, 2021.

You asked the Plan to waive the copayment for the office visit. You say that you feel the Plan should pay for 
this service. The Plan denied your request. The Plan says the services received were processed correctly per 
your plan benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for physician/practitioner services.
 
While your copayment requirement for office visits is $40, the allowed amount for this service was $18.13. 
Since this is less than your $40 copayment requirement, you are being charged the lesser amount. You have 
been asked to pay a $18.13 copayment for the office visit. The office visit 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 office visit received on 
March 15, 2021
Appeal type: Lab
Decision: Unfavorable

Explanation of decision


We decided that the Plan does not have to pay for the laboratory services provided on May 4, 2021 by an outof-
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. The Plan denied your request. The Plan says the services provided are not payable.

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 the laboratory services provided on May 4, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the echocardiography provided on May 11,
2021.

You asked the Plan to waive the deductible for echocardiography (93306). You say that the Plan should review
the deductible. The Plan denied your request. The Plan says your deductible was applied correctly as member
liability.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $500 deductible which applies to covered medical services.

The item or service you asked the Plan to waive the deductible for falls within the benefit category of covered
medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500
deductible which applies to covered medical services. This cost sharing is a contractual obligation that had not
been met at the time the bill for the echocardiography (93306) was received. You had not reached your
deductible when the provider billed the Plan on May 13, 2021. Therefore, we decided that the Plan does not
have to waive the deductible for the echocardiography provided on May 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from
March 10, 2021, through March 13, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the
charges. The Plan denied your request. The Plan says the copayment was 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 $225
copayment per day for days 1-7 for inpatient hospital care.

You have been asked to pay a $675 ($225 x 3 = $675) copayment for inpatient hospital care. The services at
issue fall within the inpatient hospital care 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 inpatient hospital care provided from March 10, 2021, through March 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nerve block injection procedure you had at an outpatient hospital facility on April 26, 2021.

You asked the Plan to waive the copayment for the nerve block injection procedure. You say that you have received this service in the past with no copayment. You said that you cannot afford this as disability doesn't pay much. The Plan denied your request. The Plan says you were charged this copayment 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 $275 copayment for surgery services in an outpatient hospital facility. 

You have been asked to pay a $275 copayment for the nerve block injection procedure. The nerve block injection procedure falls within the surgery services in an outpatient hospital facility 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 nerve block injection procedure you had at an outpatient hospital facility on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for determination of refractive state (92015) provided June 21, 2021.
You asked the Plan to pay for the refraction services. You say that you feel like your claim has been misfiled and you would like the claim refiled to the appropriate vision vendor. The Plan denied your request.
The Plan says it was verified with the provider that the refraction was performed as part of a medical exam, not a routine exam.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when performed by a routine vision care provider as part of a routine eye exam. We looked at the file and the Plan's rules. Eye refraction services are covered when performed by a routine vision care provider during a routine exam. The plan had verified with the rendering provider that the services was performed as part of a medical eye exam. Based on this information, we decided that the Plan's rules for coverage of the refraction services have not been met. Therefore, we decided that the Plan does not have to pay for determination of refractive state (92015) provided June 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy services rendered on February 21, 2021.
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 that the provider does not meet the criteria to render clinical psychology services.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. the Plan states that the rendering provider does not meet the Medicare definition
of a clinical psychologist; however, the provider is a state-licensed clinical psychologist with a doctorate's
degree in psychology. The Plan has not provided any documentation to support that the services are not
covered. Therefore, we decided that the Plan has to pay for the psychotherapy services rendered on February
21, 2021.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided from April 29, 2021 to May 20, 2021.

You asked the Plan to pay for out of network physician services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you 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 providers in this case are not a network providers 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 out of network physician services provided from April 29, 2021 to May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for medical services you received with an out-of-
network cardiologist on October 17, 2020.

You asked the Plan to waive the coinsurance for the out-of-network cardiology services. You say that you
thought this doctor was in-network. The Plan denied your request. The Plan says you were charged this
coinsurance correctly as the doctor who performed these services is not a network provider 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 50%
coinsurance for services with an out-of-network specialist.

You have been asked to pay 50% coinsurance for the out-of-network cardiology services. We confirmed that
the provider from whom you received services is an out-of-network provider. 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 medical services you received with an out-of-network cardiologist on October 17,
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Latuda.

You asked the Plan to pre-approve the Latuda. You say that the enrollee requires this medication for severe psychiatric symptoms, and you would expect a worsening of their condition if this medication is not authorized. You also say that the enrollee has been on this medication since January 29, 2016. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition 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 Latuda.

Benefits for Latuda 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty-four (24) additional PT visits.

You asked the Plan to pre-approve twenty-four (24) additional PT visits. You say that you fear that your
progress will slow and go backwards, increasing your risk for falls and possible further injury. The Plan denied
your request. The Plan says additional PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 twenty-four (24) additional PT visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is
not generally accepted as specific and effective therapy for your condition beyond what was approved by the
health Plan. You have had prior extensive therapy and the records do not demonstrate that the unique skills of a
professional therapist are required to safely and effectively provide treatment, that the services can be safely
and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been
instructed in a home exercise program. The requested services are not part of a maintenance program, are the
specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a
program to maintain your current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of twenty-four (24) additional PT visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve twenty-four (24) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on January 10, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says 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 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 out of network physician services provided to the enrollee on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on May 18, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 Medicare-covered urgently needed care visits. 

You have been asked to pay a $35 copayment for the Medicare-covered urgent care office visit provided. 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 office visit (99213) provided on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance provided by an opt out provider on April 6, 2021.

You asked the Plan to pay for periodontal maintenance. You say that you have been going to this periodontist for 25 years and it would create a hardship to switch. You say that it is disheartening to deny a procedure based on the fact that Medicare doesn't pay any dental benefits. The Plan denied your request. The Plan says payment cannot be issued for services performed by a provider that has opted out of Medicare.

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 periodontal maintenance provided by an opt out provider on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 20, 2020 by a non-participating 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 a non-participating 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 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 office visit provided on July 20, 2020 by a non-participating provider.