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

We decided that the Plan does not have to waive the deductible for the eye exam provided.
You asked the Plan to waive the deductible for the eye exam. You say that you did not know of a deductible. You say that the bill is hard to afford. The Plan denied your request. The Plan says the deductible applied correctly.
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 your in-network deductible is $250. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services. Until you have paid the in-network deductible amount, you must pay the full cost of your covered in-network services. The item or service you asked the Plan to waive the deductible for falls within the "Vision care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $250 in-network deductible applies to eye exams. This cost sharing is a contractual obligation that had not been met at the time the eye exam was received. Therefore, we decided that the Plan does not have to waive the deductible for the eye exam provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on December 23, 2019.You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for each specialist visit for Medicare-covered benefits. You have been asked to pay a $10 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefits 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 office visit provided on December 23, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the custodial services rendered.
You asked the Plan to pre-approve these services. You say that home health aide services should be covered. The Plan denied your request. The Plan says the services were custodial in nature and not covered.
The Plan must follow Medicare rules. The rules say that custodial care is not covered. We looked at the file and Medicare rules. The file shows that the services you received were not Medicare-covered home health aide services, but custodial services. The provider at issue provides only custodial care and homemaker services. 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 pre-approve the custodial services rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 19,
2019.
You asked the Plan to waive the copayment for the office visit. You say that you scheduled a wellness visit.
You say that an annual visit shouldn't have a charge. 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 for each Medicare-covered primary care physician visit.
You have been asked to pay a $20 copayment for the office visit. The office visit falls within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the
office visit was for a follow-up for chronic medical conditions. 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 provided on December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral
periapical x-ray, bitewings, comprehensive oral evaluation, and prophylaxis provided by an OON provider on
December 12, 2019.
You asked the Plan to pay for the intraoral periapical x-rays, bitewings, comprehensive oral evaluation, and
prophylaxis. You say that there are no participating providers in your area. You also say that you were told xrays
are not covered, which is incorrect according to your coverage. The Plan denied your request. The Plan
says your dental benefit does not provide coverage for intraoral/periapical x-rays. The Plan also says that the
bitewings, comprehensive oral evaluation, and prophylaxis were performed by a non-participating provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, first intraoral periapical x-ray and each
additional intraoral periapical x-ray are not among those covered under this benefit. The Plan also says that the
bitewings, comprehensive oral evaluation, and prophylaxis were performed by a non-participating provider.
You are responsible for a 50% coinsurance for bitewings, comprehensive oral evaluation, and prophylaxis each
when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the first
intraoral periapical x-ray, additional intraoral periapical x-ray, bitewings, comprehensive oral evaluation, and
prophylaxis provided by an OON provider on December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 26, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for the OON services. You say that the physician provided medically necessary
services in good faith. The Plan denied your request. The Plan says prior authorization was not obtained as
required under the plan benefits.
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 lab services provided on December 26, 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 surgical services (25076, 24071 and 27618)
You asked the Plan to pay for the surgical services. You say that you would like reconsideration because these
services are payable to the assistant surgeon. The Plan denied your request. The Plan says a Registered Nurse is
not listed as an appropriate clinician to render services as an Assistant-at-Surgery.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for surgical services (25076, 24071 and
27618)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography (CT) of the head (70450) provided November 30, 2019.You asked the Plan to pay for the CT scan. You say that the services were medically necessary.The Plan denied your request. The Plan says the service billed shares a Column One/Column Two relationship with another service billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the CT scan has a bundled relationship with code 70470 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay for Computed Tomography (CT) of the head (70450)provided November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the specialist office visit and the endoscopy provided on December 19, 2019 and December 20, 2019.You asked the Plan to waive the deductible for the specialist office visit and the endoscopy. You say that you were unaware your new plan became effective on December 1, 2019. You say you had already reached your deductible on your non-Medicare plan.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $200 deductible that applies toward specialist office visits and endoscopies, 20% of the cost for each specialist visit for Medicare-covered benefits, and 20% of the cost for each Medicare-covered outpatient hospital facility visit. The specialist office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The endoscopy also falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $200 deductible that applies towards specialist office visits and endoscopies, 20% of the cost for each specialist visit for Medicare-covered benefits, and 20% of the cost for each Medicare-covered outpatient hospital facility visit.  See chart below. Date of Service Service Allowed Amount Deductible/Coinsurance Member Liability December 20, 2019Endoscopy$170.52$200$170.52December 19, 2019Specialist office visit$70.69$200$29.48 -This is where you met your deductible amount$$41.21 -This is the remaining allowed amount ($70.69 -$29.48)20%$8.24Total$208.24This cost sharing is a contractual obligation that had not been met at the time the specialist office visit and the endoscopy were received on December 19, 2019 to December 20, 2019.Therefore, we decided that the Plan does not have to waive the deductible for the specialist office visit and the endoscopy provided on December 19, 2019 and December 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammogram (77067 and 77063) provided.
You asked the Plan to pay for the mammogram. You say that you would like reconsideration because this bill creates a financial hardship for you. The Plan denied your request. The Plan says this is a covered benefit, but you have exceeded the limits set in the EOC.
The Plan must follow Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the mammogram have not been met. Specifically, the Health Plan contract states that a screening mammogram is covered once every 12 months. The record indicates that you had a screening mammogram. The screening mammogram received exceeds the benefit limit explained in the Plan contract. Therefore, we decided that the Plan does not have to pay for a mammogram (77067 and 77063) provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the hernia repair provided on December 11, 2019.
You asked the Plan to waive the coinsurance for the hernia repair. You say that you believe there is a mistake on the copayment charge. 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 20% coinsurance for Medicare-covered surgery or other services at an outpatient hospital or an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay $824.99, which is less than the standard 20% coinsurance for the hernia repair because you met your maximum out-of-pocket. The hernia repair falls within the "Outpatient Surgery and Other Medical 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 coinsurance for the hernia repair provided on December 11, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you should not be responsible for the copayments because the physical therapy services were unnecessary. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Medicare-covered physical therapy and speech therapy services. You have been asked to pay a $40 copayment for each of the physical therapy visits. The physical therapy visits fall 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 copayments for the physical therapy visits provided.
Your complaint that the physical therapy is causing more damage is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the full hereditary cancer panel provided on June 3, 2019.
You asked the Plan to pay for the testing services. You say that you do not do referrals. The Plan denied your
request. The Plan says the testing is not being used to manage or treat a specific medical problem or diagnosis.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The testing at issue in this appeal was requested for screening purposes. The records show the cancer screening
was ordered based on the enrollee's family history of at least 2 close relatives with cancer diagnoses. There is
no documentation showing the testing was ordered by the enrollee's treating physician. Medicare does not
cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the full
hereditary cancer panel provided on June 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on September 24, 2019 by an out of network (OON) provider.You asked the Plan to pay for lab work. You say that you do not see the patient. You say that you are an independent laboratory that is contracted with the referring physician.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-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 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 forlab work provided on September 24, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories.You asked the Plan to pre-approve a Group 2 power wheelchair and accessories. You say that you need a power wheelchair.The Plan denied your request. The Plan says the clinical information does not show that you meet criteria for a power wheelchair.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not show if your condition can be improved by a walker, cane or manual wheelchair or if you can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the sedation services rendered on August 13, 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 procedure code 99152 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99152 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes.We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation that moderate sedation services were performed. 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 sedation services rendered on August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis (LSO) rendered on January 14, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were not medically necessary.The Plan must follow Medicare rules. Medicare rules say that the LSO is covered when specific criteria are met.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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the submitted documentation does not support that an LSO was medically necessary to reduce pain by restricting mobility of the trunk, to facilitate healing following an injury to the spine or related soft tissues, to facilitate healing following a surgical procedure on the spine or related soft tissue, or to otherwise support weak spinal muscles and/or a deformed spine for the enrollee. The services werenot reasonable or medically 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 these services have not been met.Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2020) deluxe lens feature (V2702) anti-reflective coating (V2750) progressive lens (V2781) polycarbonate lens (V2784) purchased January 29, 2020.You asked the Plan to pay for the vision services. You say that you were not able to see with your previous glasses. You went to this provider and they said they took the insurance. The representative did not know much of the process since you was her first customer.The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.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 rendered by an in-network provider.We looked at the file and the Plan's rules. enrollee's must receive their medical services from an in-network provider Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay for deluxe frames (V2020) deluxe lens feature (V2702) anti-reflective coating (V2750) progressive lens (V2781) polycarbonate lens (V2784) purchased January 29, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient physical therapy services provided from October 18, 2019 to October 31, 2019.You asked the Plan to pay for the outpatient physical therapy services. You say that you were advised that the enrollee had been discharged from hospice on October 17, 2019.The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on October 17, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay for the outpatient physical therapy services provided from October 18, 2019 to October 31, 2019.