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

We decided that the Plan does not have to pay for the tetanus vaccine (90715) and administration (90471) provided on August 2, 2019.You asked the Plan to pay for the tetanus vaccine and administration. You say that you were required to get this vaccine.The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D prescription drug plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the tetanus vaccine and administration.Therefore, we decided that the Plan does not have to pay for the tetanus vaccine (90715) and administration (90471) provided on August 2, 2019.Benefits for the tetanus vaccine and administration may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 4, 2019 to October 23, 2019.You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.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 proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 4, 2019 to October 23, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bridges fabricated on teeth numbers 5 through 9 (procedures codes D6740 and D6245), the crown lengthening (procedure code D4249) on tooth number 6 from May 2, 2018 through April 3, 2019.You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says the services are not a covered benefit under the plan.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. The services are not listed in your EOC as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pay for bridges fabricated on teeth numbers 5 through 9 (procedures codes D6740 and D6245), the crown lengthening (procedure code D4249) on tooth number 6 from May 2, 2018 through April 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgery provided from March 26, 2019 to March 27, 2019.You asked the Plan to pay for the outpatient surgery. You say that the services were provided in good faith.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider. The Plan also says there was no prior authorization for the services.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollees teeth or the structures directly supporting the teeth. These are dental services that are not covered or paid for by Medicare.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 outpatient surgery provided from March 26, 2019 to March 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 8, 2019.You asked the Plan to pay for the physician's 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 physician 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 physician's services provided on May 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 12, 2019 by the out of network provider.You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says the services were not urgent or emergent in nature.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 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 office visit provided on June 12, 2019 by the out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the enrollee's blood sugar was extremely low and he was unresponsive. You stated that you called an ambulance and the responders came and treated the enrollee. The enrollee became responsive and his condition stabilized. You say that you denied transportation to the hospital because the responders deemed it unnecessary. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on March 13, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay fo rlaboratory testing provided on June 3, 2019.You asked the Plan to pay for lab tests. You say that the ordering physician's medical record is kept by the physician's office and not supplied to you, and you only have the information necessary to accomplish the ordered laboratory testing.The Plan denied your request. The Plan says that the denial of payment for these services is correct, because the ordering physician did not submit medical records needed in order to determine the clinical utility of testing.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician is in-network or out-of-network with the Plan. The Plan did not submit documentation of prior notice that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care, which would justify coverage of this claim. Therefore, the Plan has not shown that their decision to deny payment for these services is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for laboratory testing provided by Medical Diagnostic Laboratories on June 3, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate forthe office visit provided on July 29, 2019 by the out of network provider.You asked the Plan to pay the in network rate forthe physician service. You say that the enrollee was seeking immediate medical care.The Plan denied your request. The Plan says authorization was not obtained before the service was provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the service. The Plan also says that the service was not urgent or emergent.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 the in network rate 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 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 the in network rate for these items/services.Therefore, we decided that the Plan does not have to pay the in network rate forthe office visit provided on July 29, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, and drug testing provided on April 23, 2019.You asked the Plan to pay for the drug testing. You say that this code does not require authorization. You say also say that this code has been paid previously for the date of service March 12, 2019.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee.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 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 drug testing provided on April 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on June 27, 2019.
You asked the Plan to waive the copayment for the ambulance services. You say that you had fallen and the ambulance services were medically necessary. The Plan denied your request. The Plan says you were charged this cost sharing correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $265 copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $265 for these services. 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 provided on June 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the shoulder (73221-52) provided on July 22, 2019.You asked the Plan to waive the copayment for the MRI of the shoulder. You say that you should not be responsible for the copayment since you experienced a panic attack and the test was not able to be completed.The Plan denied your request. The Plan says based on Medicare billing criteria the claim was billed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such ascopayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for diagnostic radiology services. You have been asked to pay $116.70 (the allowed amount) for the MRI of the shoulder. An MRI of the shoulder falls within the diagnostic radiology 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 fora magnetic resonance imaging (MRI) of the shoulder (73221-52) provided on July 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from June 23, 2019 through June 25, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing the member's cost-share responsibility for the services the member received due to the quality of care they received. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that the enrollee received inpatient hospital care from June 23, 2019 through June 25, 2019. The enrollee is asked to pay a $370 copayment per day for June 23, 2019 through June 24, 2019. 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 inpatient hospital care provided to the enrollee from June 23, 2019 through June 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a duplex scan of extremity veins (93970) provided on July 15, 2019.
You asked the Plan to waive the copayment for a duplex scan of extremity veins. You say that you were not told there would be a $100 copayment for the scan of your legs. You say you are retired and cannot afford to pay your copayment. The Plan denied your request. The Plan says outpatient diagnostic tests have a $100 copayment for each radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility.
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 $100 copayment for outpatient diagnostic tests. You have been asked to pay a $100 copayment for a duplex scan of extremity veins. This service falls within the outpatient diagnostic tests benefits category. The duplex scan falls into the category of specialized scans. The provider billed procedure code 93970 in the amount of $991. The allowed amount for this service is $101.64. The Plan applied a $100 copayment to the diagnostic service. 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 duplex scan of extremity veins (93970) provided on July 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe electrocardiogram provided on May 29, 2019 by out of network provider. You asked the Plan to pay for the electrocardiogram. 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 electrocardiogram provided on May 29, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on July 31, 2019.You asked the Plan to pay for the physician 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 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 physician services provided on July 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on June 16, 2019 through June 17, 2019.You asked the Plan to pay for the acute inpatient level of care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says hospitalization does not meet criteria for inpatient status.The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollee's condition can be managed safely only in the inpatient hospital setting. 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 acute inpatient level of care. Our reviewer says that care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. Our physician reviewer found inpatient services were not supported by the documentation.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 acute inpatient level of care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on June 16, 2019 through June 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy rendered to you on June 26, 2019.You asked the Plan to waive the copayment for these services. You say that the services were for a routine screening.The Plan denied your request. The Plan says the copayment was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for each Medicare-covered surgical procedure in an outpatient hospital facility. Review of the file shows that you had a diagnostic colonoscopy on June 26, 2019. The colonoscopy was diagnostic and not screening in nature because a polyp was removed. You have been asked to pay a $150 copayment for these services. These services fall within the Medicare-covered surgical procedure in an 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 the diagnostic colonoscopy rendered to you on June 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing for 22 or more drug classes provided on July 2, 2019.
You asked the Plan to pay for the definitive drug testing. You say that the records and the order support that this testing was medically necessary as ordered. The Plan denied your request. The Plan says the order at issue does not clearly indicate the drug classes being requested for testing.
The Plan must follow Medicare rules. Medicare rules say that lab services may be covered when ordered by a treating provider. In this case, the order form lacks sufficient detail to support that testing for 22 or more drug classes was intended. Therefore, we decided that the Plan does not have to pay for the definitive drug testing for 22 or more drug classes provided on July 2, 2019.