Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on September 19, 2020.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 diagnostic radiology services provided on September 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug.

You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you thought that because the drug was approved there would be no cost and the enrollee cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare Part B prescription drugs.

The enrollee received a Medicare Part B drug. The allowed amount is $4,622.32 and 20% of that is $924.46.

The enrollee has been asked to pay the total coinsurance amount of $924.46 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit provided on September 21, 2020.
You asked the Plan to pay for the annual wellness visit. You say that the Plan should pay something towards your visit. The Plan denied your request. The Plan says you were charged the deductible correctly for the out-of-network visit.
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 you have a $750 deductible. The out-of-network service you received falls under the deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible. This cost sharing is a contractual obligation that had not been met at the time the annual wellness visit was received on September 21, 2020. Therefore, we decided that the Plan does not have to pay for the annual wellness visit provided on September 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on October 6, 2020.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you should only owe 20% coinsurance and were overcharged. 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 $315 copayment for a diagnostic colonoscopy provided at an ambulatory surgical center. You received a diagnostic colonoscopy on October 6, 2020, at an ambulatory surgical center. Therefore, you are responsible to pay the $315 copayment. You have been asked to pay a $315 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls 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 a diagnostic colonoscopy provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam with photos provided on July 30, 2020, by an
OON provider.
You asked the Plan to pay for the eye exam with photos. You say that the service is medically necessary. The
Plan denied your request. The Plan says this service done by an out-of-network provider is not covered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested 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 eye exam with photos provided on July 30,
2020, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the lung removal (32480) and thoracic lymphadenectomy
(38476) provided on August 12, 2020.
You asked the Plan to pay for the lung removal and thoracic lymphadenectomy. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the diagnosis code
billed does not specify a side while the codes are appended with modifier LT indicating the left side.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT codes 38746 and 32480 are not supported in the record. Specifically, the diagnosis code
billed indicates that the laterality is unspecified. The modifiers appended to these codes and the medical records
indicates this service was specific to the left side. There is a more appropriate diagnosis code to use in this case.
Based on this information, we decided that Medicare rules for coverage of the lung removal and thoracic
lymphadenectomy have not been met. Therefore, we decided that the Plan does not have to pay for the lung
removal (32480) and thoracic lymphadenectomy (38476) provided on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ophthalmology services provided on November 25, 2020, and November 30, 2020.
You asked the Plan to waive the copayments for ophthalmology services. You say that you disagree with the charges because you have diabetes and your glaucoma was flaring. 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 $45 copayment per specialist visit. You received ophthalmology services on November 25, 2020, and November 30, 2020. Therefore, you are responsible to pay a $45 specialist copayment per each visit. The total amount you owe is: $90. You have been asked to pay the total copayment amount of $90 for ophthalmology services. Ophthalmology services fall within the physician/practitioner services, including doctor's office visits 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 ophthalmology services provided on November 25, 2020, and November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for two units of code 26040 provided on July 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the number of allowed units was exceeded.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 26040 is 1. You billed 2 units of this code, exceeding the MUE. 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 two units of code 26040 provided on July 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided June 16, 2020.
You asked the Plan to pay for the hearing aids. You say that the hearing aids should be covered. The Plan denied your request. The Plan says hearing aids are only eligible for coverage when obtained from a plan selected vendor.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when obtained from a plan selected vendor. We looked at the file and the Plan's rules. The hearing aids were not obtained from the plan's selected vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical procedure and services (12032, 11603, 11104) provided on August 5, 2020, to September 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the surgical procedure and services. You say that you did not realize you were not contracted with this specific Plan, but you are contracted with other plans provided by this company. The Plan denied your request. The Plan says you are not contracted with this Plan, no referral was provided, and the care provided was not urgent.
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 surgical procedure and services (12032, 11603, 11104) provided on August 5, 2020, to September 25, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745).
You asked the Plan to pay for neuromuscular stimulator. You say that the item provided was medically necessary for the enrollee. The Plan denied your request. The Plan says there is no evidence of an examination before the provider ordered the item.
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 pay for neuromuscular stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a physical examination of the lower extremities would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the neuromuscular stimulator was medically reasonable and necessary in this case, as there is insufficient documentation of a credible evaluation and physical examination of the knees. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuromuscular stimulator have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator (E0745).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry visit provided on November 5, 2020.
You asked the Plan to waive the copayment for the podiatry visit. You say that you have type 2 diabetes and have to have your toenails cut. You say you do not believe you owe a 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 $30 copayment for specialty physician visit. You have been asked to pay a $30 copayment for the podiatry visit. The podiatry visit falls within the "Podiatry services" category. The medical record shows your nails were debrided. 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 podiatry visit provided on November 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services.

You asked the Plan to waive the copayment for the outpatient hospital services. You say that you should not have a copayment for the second surgery. 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 $360 copayment for Outpatient Hospital Services.

You have been asked to pay $299.33 copayment for the outpatient hospital services. The outpatient hospital services fall within the Outpatient Hospital Services benefit category. The provider's contracted rate is less so your copayment is less. 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 outpatient hospital services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal protective equipment (D1999) provided on September 29, 2020.
You asked the Plan to pay for the personal protective equipment. You say that the services should be covered. The Plan denied your request. The Plan says personal protective equipment (PPE) is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Additionally, the Plan confirmed with the dental office that there is no enrollee liability for the services that you received on this date of service. Therefore, we decided that the Plan does not have to pay for the personal protective equipment (D1999) provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided by an OON provider.

You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you have been going to this dentist for many years. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that services performed by an OON provider are not covered because your healthcare plan does not have OON 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and sleeves (L1851, L2397).

You asked the Plan to pay for the knee orthoses and sleeves. You say that the items provided were medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there is no documentation that an examination ever occurred and medical necessity criteria was not met.

The Plan follows Medicare rules. Medicare rules say that for coverage of the requested knee orthosis, knee instability must be documented by examination of the beneficiary and objective description of joint laxity.

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 knee orthoses and sleeves. Our reviewer says that the items were not reasonable and necessary. Our physician reviewer found there is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee orthoses and sleeves have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and sleeves (L1851, L2397).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on September 16, 2020.
You asked the Plan to pay for foot orthotics. You say that this was needed to correct your broken toe. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on September 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the x-ray of the spine (72100) and x-ray of the pelvis (72170).

You asked the Plan to reduce the copayment for the x-rays. You say that you expected to pay $20 for these services. The Plan denied your request. The Plan says x-ray imaging has a $30 copayment per service.

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 $30 copayment for each standard x-ray service.

You have been asked to pay a $54.30 copayment two x-ray services ($30 + $24.30). 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 reduce the copayment for the x-ray of the spine (72100) and x-ray of the pelvis (72170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the face-down-recovery chair.

You asked the Plan to pay for the face-down-recovery chair. You say that this device was necessary following the enrollee's surgery. The Plan denied your request. The Plan says this device is not considered medical in nature.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the face-down-recovery chair.