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

We decided that the Plan does not have to pay for the eye refraction (92015) received February 16, 2021.

You asked the Plan to pay for the eye refraction. You say that you had an acute dry eye attack.The Plan denied your request. The Plan says the eye refraction was performed as a medical procedure and is therefore not covered.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when performed as part of a routine eye exam.

We looked at the file and the Plan's rules. The Plan only covers eye refractions during a routine eye exam. You received the eye refraction as part of a medical exam. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) received February 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient surgery and radiology services provided on January 29, 2021 by an out of network (OON) provider.

You asked the Plan to pay for an outpatient surgery and radiology services. You say that these services were medically necessary.The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is 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 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 an outpatient surgery and radiology services provided on January 29, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services provided on January 7, 2021 by an out of network (OON) provider.

You asked the Plan to pay for telehealth services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there was no referring provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for telehealth services provided on January 7, 2021 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 pneumatic compression device (E0675) and segmental gradient pressure pneumatic appliance (E0673) provided on October 20, 2020.
You asked the Plan to pay for the pneumatic compression device and segmental gradient pressure pneumatic appliance. You say that you would like reconsideration because this equipment is covered and was billed with the correct place of service. The Plan denied your request. The Plan says this request is not covered because the member does not have lymphedema or venous insufficiency with ulcers.
The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0675 to treat PAD is not eligible for reimbursement and if the base PCD is not covered, related accessories are not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device and segmental gradient pressure pneumatic appliance have not been met. Specifically, a PCD coded E0675 is not a covered benefit. Because the base code is not covered, the requested accessory is also not eligible for reimbursement. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental gradient pressure pneumatic appliance (E0673) provided on October 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on January 6, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were not aware that this service was only covered one time every three years. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.
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, comprehensive oral evaluation is limited to one procedure every three years. The record shows that you received a comprehensive oral evaluation on June 23, 2020 and your comprehensive oral evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ophthalmology office visit to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the ophthalmology office visit. You say that you would like reconsideration because you have been seeing this provider for 15 years and do not want to risk starting over with a new ophthalmologist. The Plan denied your request. The Plan says you can receive necessary care for your condition in-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 provider at issue in this case is not a network provider with the Plan. 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 ophthalmology office visit. Our reviewer says that continued service with the non-network ophthalmologist for the glaucoma is not medically necessary. Based on the medical notes and appeal argument, you had glaucoma that can be treated medically by an ophthalmologist within the health plan's network. Our physician reviewer found records do not indicate that the glaucoma was poorly controlled nor that transfer of care would pose any additional health risk. There was no emergent condition or special services required that would necessitate treatment by the non-network ophthalmologist.

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 ophthalmology office visit have not been met.

The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the ophthalmology office visit. Therefore, we decided that the Plan does not have to pre-approve the ophthalmology office visit to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on January 6, 2021, to January 13, 2021 by an out of network (OON) provider.
You asked the Plan to pay for wound care. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 wound care provided on January 6, 2021, to January 13, 2021 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for extracapsular cataract removal provided on December 11, 2020.

You asked the Plan to waive the deductible and copayment for extracapsular cataract removal. You say that you were given the wrong cost-sharing information and disagree with the charges.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. Your contract with the Plan says that there is a $500 deductible. Your contract with the Plan also clearly says that after the $500 deductible has been met, enrollee's must also pay a $325 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.

You received extracapsular cataract removal on December 11, 2020. The record shows that you had paid $0 toward the $500 deductible prior to receiving the services. Therefore, you are responsible to pay the $500 deductible. Now that the $500 deductible has been met, you are also responsible to pay the $325 copayment. The total amount you owe is: $825. 

The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit category outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time extracapsular cataract removal was received on December 11, 2020.Therefore, we decided that the Plan does not have to waive the deductible and copayment for extracapsular cataract removal provided on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and ECG provided by an out-of-network provider on October 19, 2020.
You asked the Plan to pay for the office visit and ECG. You say that you were advised that no referrals or authorization was required during COVID. You say that the services were rendered in good faith and you are willing to accept in-network rates as payment in full. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not 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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit and ECG provided by an out-of-network provider on October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 7, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you had repeated lab work provided. You say that you were advised to follow up with your primary. The Plan denied your request. The Plan says prior authorization was not obtained by a participating 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 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 lab work provided on December 7, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses and frames purchased on December 9, 2019, and February 5, 2020.

You asked the Plan to pay for the eyeglasses and frames. You say that you would like reconsideration because you were not able to obtain the necessary documentation due to COVID-19.The Plan denied your request. The Plan says these claims were not submitted within 1 year of the dates of service.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the eyeglasses and frames was not filed until February 9, 2021. 

This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for the eyeglasses and frames purchased on December 9, 2019, and February 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the MRI to be provided by an out-of-network provider.
You asked the Plan to pay for the MRI. You say that the records warrant the medical necessity of the service billed and the claim should be reprocessed for payment. The Plan denied your request. The Plan says prior authorization was required but not obtained.
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 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 MRI to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the dental services (D0120, D1110, D1206) received January 19, 2021.
You asked the Plan to pay an additional amount for the dental services. You say that you should have a $0 copayment. The Plan denied your request. The Plan says you have been charged the difference between the Plan's maximum allowable charge and what was billed by the out-of-network 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 the dental services when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. The Plan contract states you will save more when you receive care from an in-network dental provider. You can get care from an out-of-network dental provider, but you may pay more. The Plan has provided coverage of the requested dental services based on the Plan's maximum allowable charge. You are responsible for the difference between the Plan's allowed amount and what was charged by the out-of-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 an additional amount for the dental services (D0120, D1110, D1206) received January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hair transplantation consultation to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve an OON hair transplantation consultation. You say that this is medically necessary. The Plan denied your request. The Plan says this is available in-network. Please note that the Plan has indicated that they have approved the requested service with an in-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 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 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a hair transplantation consultation to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for skilled nursing facility (SNF) care provided on January 13, 2021, through January 23, 2021.

You asked the Plan to waive the co-payment for SNF care. You say that the services should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $184 co-payment each day 21-100 for skilled nursing facility (SNF) care.

You have been asked to pay a $184 co-payment each day 21-100 for SNF care ($184 x 10 = $1840). SNF care falls within the skilled nursing facility (SNF) 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 co-payment for skilled nursing facility (SNF) care provided on January 13, 2021, through January 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for medical supplies provided on January 14, 2021, to February 9, 2021 by an out of network (OON) provider.
You asked the Plan to pay for medical supplies. You say that you would like the Plan to pay for these months. You say that you are dis enrolled from this Plan now. The Plan denied your request. The Plan says there are in-network providers available for these services. The plan says that the member's primary care physician did not refer these services.
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 medical supplies provided on January 14, 2021, to February 9, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair/modification of a hearing aid (V5014) received April 7, 2021.
You asked the Plan to pay for the repair/modification of a hearing aid. You say that this service has been covered in previous years. The Plan denied your request. The Plan says you did not receive your hearing aids from the hearing vendor that administers your plan's hearing benefit, therefore pay cannot be made.
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 aid related services for Plan vendor hearing aids. We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the repair/modification of a hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the repair/modification of a hearing aid (V5014) received April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services and lab work provided on November 11, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician services and lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the member's primary care physician did not refer these services.

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 physician services and lab work provided on November 11, 2020 by an out of network (OON) provider.