Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on December 11, 2019.You asked the Plan to pay forthe dental services. You say that you did not know that this provider was not in network.The Plan denied your request. The Plan says that dental services must be provided by a 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. The Plan covers certain dental services when you visit a participating dental network provider.We looked at the file and Medicare rules. The file indicates you did not receive these services from a participating dental network provider. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pay forthe dental services provided on December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that coverage and payment for Medicare telehealth services includes consultation, office visits,
individual psychotherapy, and pharmacologic management delivered via a telecommunications system.
Eligible geographic areas include rural health professional shortage areas (HPSA) and counties not classified as
a metropolitan statistical area (MSA). The originating site for telehealth services (location to which the enrollee
presents) must be a practitioner's office, hospital, rural health clinic (RHC), federally qualified health center
(FQHC), skilled nursing facility or community mental health center. You can find this rule in the Medicare
Claims Processing Manual, Chapter 12, Sections 190.1 and 190.2.
The rules say that for eligible telehealth services, telecommunications systems substitute for an in-person
encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an originating
site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional
Shortage Area (HPSA) located in a rural census tract. You can find this in the CMS MLN document entitled
"Telehealth Services."
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis and the knee orthosis provided by on January 13, 2019. You asked the Plan to pay for the lumbar-sacral orthosis (L0650) and the knee orthosis (L1832). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no physician order, no itemized shipping/billing invoice to indicate the specific supplies, or Proof of Delivery indicating the billed items were delivered. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis and the knee orthosis provided on January 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided by a participating hospital on November 20, 2019 to November 27, 2019.
You asked the Plan to waive the copayment for an outpatient surgery. You say that there was no operating room, just a physician's examination room. The Plan denied your request. The Plan says the correct copayment has been applied.
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 outpatient surgery/Basic/outpatient hospital facility. You have been asked to pay $345.52 which is less than your copayment amount of $350 for an outpatient surgery. The total amount you are being asked to pay is $691.04 ($345.52 x 2 surgeries = $691.04). Wound care is considered an outpatient surgery; therefore, the correct copayments have been applied. An outpatient surgery falls within the outpatient surgery/Basic/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 wound care provided by a participating hospital on November 20, 2019 to November 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Duopa 4.63 mg - 20mg/ml suspens.
You asked the Plan to pre-approve Duopa 4.63 mg - 20mg/ml suspens. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Duopa 4.63 mg - 20mg/ml suspens.
Benefits for Duopa 4.63 mg - 20mg/ml suspens may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on November 7, 2019.You asked the Plan to pay for the laboratory testing. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 laboratory testing provided on November 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator provided on December 3, 2019 by an out of network provider.
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that you had to buy the portable oxygen concentrator for quality of life, travel, appointments, and functions. The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network purchase.
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 reimburse you for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. Medicare rules say that only rented oxygen equipment is eligible for coverage.
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 at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to reimburse you for the item. Purchased oxygen equipment is statutorily non-covered by Medicare. Therefore, we decided that the Plan does not have to reimburse you
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 22, 2020 and January 29, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the laboratory services. 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 laboratory services provided on January 22, 2020 and January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the plan requires you to receive care from providers who are part of your primary care physician's (PCP) specialty 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The contract with the Plan also says that the plan requires the enrollee to receive care from providers who are part of the enrollee's primary care physician's (PCP) specialty network.
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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on July 12, 2019 to November 8, 2019.You asked the Plan to waive the copayment for specialist services. You say that no one ever told you that there would be a copayment or discussed any insuranceinformation. The Plan denied your request. The Plan says the correct copayment has been applied.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 a $30 copayment for physician/practitioner services/specialist. The enrollee has been asked to pay a $30 copayment for specialist services. The total amount you are being asked topay is $60 ($30 x 2 visits = $60). Specialist services fall within the physician/practitioner services/specialist 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 copayment for specialist services provided by a participating provider on July 12, 2019 to November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an Epoetin Alfa injection (96372, J0885) provided September 12, 2019.
You asked the Plan to pay for an Epoetin Alfa injection. You say that these services are payable according to the Physician Fee Schedule. The Plan denied your request. The Plan says the claim processed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that all charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient).
We find that the services at issue are not supported as billed. Specifically, the record shows that a claim was billed on TOB 131 (hospital outpatient). The record also shows that the services were not reported under revenue code 0510 (clinic visit). The services do not meet exception criteria for separate reporting. Based on this information, we decided that Medicare rules for coverage of an Epoetin Alfa injection have not been met.
Therefore, we decided that the Plan does not have to pay for an Epoetin Alfa injection (96372, J0885) provided September 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hetlioz Cap 20mg.
You asked the Plan to pre-approve Hetlioz Cap 20mg. You say that the medication is necessary. The Plan
denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate
pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Hetlioz Cap 20mg.
Benefits for Hetlioz Cap 20mg 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on September 9, 2019.You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.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 tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on October 11, 2019 to October 14, 2019 by an out of network (OON) provider. You asked the Plan to pay for the chiropractic 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 chiropractic services provided on October 11, 2019 to October 14, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the breast (76642) provided December 27, 2019. You asked the Plan to waive the copayment for the ultrasound. You say that the service was part of a screening mammogram and there should be no copayment. The Plan denied your request. The Plan says there is no screening mammogram copayment, but the correct copayment was applied for the ultrasound performed during the same visit.
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 Basic Imaging Services. You have been asked to pay a $40 copayment for the ultrasound. The ultrasound falls within the Basic Imaging 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 an ultrasound of the breast (76642) provided December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (G0283, 97035, L0626) you
received from October 21, 2019, to November 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not
covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the services at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the chiropractic services (G0283, 97035, L0626) you received from October
21, 2019, to November 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient lab work provided by a participating provider on November 5, 2019.
You asked the Plan to waive the copayment for outpatient lab work. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 outpatient diagnostic tests/in-network/lab services. You have been asked to pay a $20 copayment for outpatient lab work. Since the lab work provided was diagnostic, the correct copayment has been applied. Outpatient lab work falls within the outpatient diagnostic tests/in-network/lab 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 outpatient lab work provided by a participating provider on November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services provided on October 30, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe chiropractic services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OONprovider.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 forthe chiropractic services provided on October 30, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the heated humidifier provided on December 12, 2019. You asked the Plan to waive the coinsurance for the heated humidifier. You say that you should not be responsible for this. The Plan denied your request. The Plan says that you pay a 20% coinsurance for durable medical equipment. 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% coinsurance for Durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for the heated humidifier. The heated humidifier falls within the Durable medical equipment (DME) and related 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 coinsurance for the heated humidifier provided on December 12, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services (99285, 70450) provided December 19, 2019.You asked the Plan to waive the copayment for the Emergency Room Services. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.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 $120 copayment for Emergency Care. You have been asked to pay a $120 copayment for the Emergency Room Services. The Emergency Room Services fall within the Emergency 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 Emergency Room Services (99285, 70450) provided December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 21, 2019 by an out of 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 of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 laboratory services provided on November 21, 2019by an out of network (OON) provider.