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

We decided that the Plan does not have to waive the copayment for the ambulance transportation service provided.

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). The enrollee's contract with the Plan clearly says that enrollees must paya $200 copayment for ground ambulance transportation services. 

The enrollee has been asked to pay a $200 copayment for the ground ambulance transportation service provided. 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 copayment for the ambulance transportation service provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foran eye and medical exam for diagnosis and treatment (92014) and assessment for prescriptive eye wear (eye refraction) (92015) provided on September 29, 2020.You asked the Plan to pay fora diagnostic eye exam and refraction. You say that the services should be covered.The Plan denied your request. The Plan says the diagnostic eye exam is covered with a $35 copayment and the eye refraction is not a covered service.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. They do cover diagnostic eye exams with a $35 copayment.The services you asked the Plan to pay for are considered routine vision services or eyewear. Specifically, you do not have a supplemental vision plan, this means eye refractions are not covered services. Diagnostic eye exams are covered with a $35 copayment, which was applied correctly.Therefore, we decided that the Plan does not have to pay foran eye and medical exam for diagnosis and treatment (92014) and assessment for prescriptive eye wear (eye refraction) (92015) provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral X-rays (D0220) and additional intraoral Xrays
(D0230) provided on August 18, 2020.
You asked the Plan to pay for the first intraoral X-rays and additional intraoral X-rays. You say that the
services provided were medically necessary for your condition. The Plan denied your request. The Plan says
these are not covered services under your benefit.
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. Therefore, we decided that the Plan does not have to pay for the first
intraoral X-rays (D0220) and additional intraoral X-rays (D0230) provided on August 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on July 6, 2020.
You asked the Plan to pay for the home visit. You say that the provider depends on the hospital staff to obtain proper authorization from the enrollee's insurance. You say that the physician provided medically necessary services and should not be penalized for failure to obtain authorization. The Plan denied your request. The Plan says the provider is not a network provider with the Plan and the services were not referred by a network 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on July 6, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health skilled nursing service (G0299) rendered by the out of network (OON) provider on August 28, 2020.You asked the Plan to pay forthis 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 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 theservice at issue. We found no exception that would require the Plan to pay for theservice.Therefore, we decided that the Plan does not have to pay forthe home health skilled nursing service (G0299) rendered by the out of network (OON) provider on August 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services (A0425, A0428)
provided on August 21, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that you were under the
impression that the ambulance ride would be fully covered. The Plan denied your request. The Plan says the
copayment has applied correctly in this case.
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 $350
copayment for ambulance services.
You have been asked to pay a $350 copayment for the ambulance services. The services provided fall within
the ambulance services benefit category. This means that you have been asked to pay the correct amount based
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the
ambulance services (A0425, A0428) provided on August 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the prostate specific antigen (PSA) testing rendered on
September 24, 2020.
You asked the Plan to pay for these services. You say that you were following your doctor's advice for the PSA
test. The Plan denied your request. The Plan says the services exceed the benefit limit.
The Plan must follow Medicare rules. The rules say that a PSA test is covered once every twelve months for
men aged 50 or older.
We looked at the file and Medicare rules. The file shows that you had a PSA test on February 27, 2020, for
which the Plan approved and paid. The PSA test on September 24, 2020, was performed less than twelve
months from your previously covered PSA test. Therefore, we decided that the Plan does not have to pay for
the prostate specific antigen (PSA) testing rendered on September 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the endodontic therapy provided on July 13, 2020.
You asked the Plan to pay more for the endodontic therapy. You say that a Plan representative advised that this
service would be fully covered. The Plan denied your request. The Plan says your annual $750 dental benefit
has been exhausted.
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 Plan offers a maximum plan
benefit coverage amount of $750 per year, which applies to all supplemental dental services. The contract says
that you are responsible for any cost above the $750 maximum. The record shows that you met the annual
maximum benefit on July 13, 2020, and your annual maximum benefit has been exhausted. Therefore, we
decided that the Plan does not have to pay more for the endodontic therapy provided on July 13, 2020.
Your complaint about possibly being misinformed by the Plan 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted surgical services provided to the enrollee on September 23, 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 According to the Medicare Surgery Manual, no other person can be paid. If the person who assists at surgery is a surgical technician, a first surgical assistant, scrub nurse or bears any title other than those listed, the service is not payable by Medicare and is not billable to the patient.
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 assisted surgical services provided to the enrollee on September 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan (78815) provided on May 18, 2020.
You asked the Plan to pre-approve a PET scan. You say that this should be covered. The Plan denied your request. The Plan says this was not billed with an appropriate diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate diagnosis code. We looked at the file and Medicare rules. The billed diagnosis code, C64.9, is not listed as an appropriate code. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan (78815) provided on May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1843) and the lower suspension sleeve (L2397) provided on August 4, 2020.
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as they were billed with an incorrect place of service code.
The Plan must follow Medicare rules. Medicare rules say that the place of service billed for DMEs should indicate or reflect the location in which the item is being used. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these items have not been met. Specifically, the place of service code was billed incorrectly as it should indicate or reflect the location in which the items are being used. Place of service code 11 was billed indicating an office setting, instead of a code for the location in which the enrollee is utilizing these items. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1843) and the lower suspension sleeve (L2397) provided on August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2025) progressive lenses, per lens (V2781)
tint, photochromatic, per lens (V2744) anti-reflective coating, per lens (2750) purchased September 17, 2020
from an out of network provider.
You asked the Plan to pay for the vision services. You say that you were under the impression that you had
coverage for glasses. You feel that it should have been covered since you were told that you had coverage. 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 when the services are received from an in network provider.
We looked at the file and the Plan's rules. Routine eye exam services and routine vision hardware services are
not available out of network. 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
(V2025) progressive lenses, per lens (V2781) tint, photochromatic, per lens (V2744) anti-reflective coating, per
lens (2750) purchased September 17, 2020 from an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 7, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 medical services provided on October 7, 2020
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the hearing aids purchased on August 13, 2020.
You asked the Plan to reimburse you for the hearing aids. You say that the hearing aids were purchased from a qualified supplier. The Plan denied your request. The Plan says you did not utilize your hearing aid benefit and utilized a provider not in the vendor network.
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 from a specific network hearing aid provider. We looked at the file, and the Plan's rules. 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 reimburse you for the hearing aids purchased on August 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four monitoring (95999) provided on January 14, 2020.You asked the Plan to pay forthe train of four monitoring. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says request for separate payment for these services is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 95999 is not supported in the record. Specifically, train of four monitoring is considered integral to the primary procedure and not separately reimbursable. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring havenot been met.Therefore, we decided that the Plan does not have to pay fortrain of four monitoring (95999) provided on January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The power seat elevation system at issue in this appeal - E2300 - 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.
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 other denied accessories (E2311, E2313, and E2377). Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the expandable harness (E2313), the (E2311) electronic connection, and the (E2377) expandable controller are not medically necessary. The documentation does not reveal that the enrollee needs an expandable controller to operate other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.), non-proportional input devices (e.g., sip and puff, head array, etc.), or to operate 3 or more powered seating actuators through the drive control. The documentation does not reveal the enrollee needs the expandable controller to operate a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or for an attendant control. The enrollee has sufficient strength in the upper extremities and functional ability to operate any power options through their own individual switches. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the drug testing services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on October 8, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on July 31, 2020.
You asked the Plan to waive the copayment for the ambulance ride. You say that you do not believe you should be responsible for the copayment because this was a medical emergency and you had no choice in the transportation. 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 $295 copayment for each covered, one-way ambulance trip, by ground or water. You have been asked to pay a $295 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance ride provided on July 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the patient appears to be more stable but requires additional non-complex short-term
acute care services which can be safely completed at the current facility. The patient does not require services
at the LTACH that are not already available and covered at the current facility. There are no services at the
LTACH that the patient requires that are not already available and covered at the current facility. Therefore,
this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower
level of care may be considered soon.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.