Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient rehabilitation services provided on February 17, 2020.
You asked the Plan to waive the deductible for outpatient rehabilitation services. You say that you feel that you should not be responsible for the full amount. 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 $750 deductible for outpatient rehabilitation services. You received outpatient rehabilitation services on February 17, 2020. The record shows that you had only paid $172.58 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed mount of $213.39. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient rehabilitation services. This cost sharing is a contractual obligation that had not been met at the time outpatient rehabilitation services was received on February 17, 2020. Therefore, we decided that the Plan does not have to waive the deductible for outpatient rehabilitation services provided on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dental extractions for the enrollee.
You asked the Plan to pay for the extractions. You say that this should be reconsidered. The Plan denied your request. The Plan says Medicare does not provide coverage for dental services, and the enrollee does not have a supplemental benefit available.
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 your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for dental extractions for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided to the enrollee on July 14, 2019.
You asked the Plan to pay for the paramedic intercept services. The Plan denied your request. The Plan says that this is not a covered service.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided to the enrollee on July 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 20, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services provided on November 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 6, 2020 by a nonnetwork
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 a non-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 referring provider 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 medical services provided on January 6, 2020 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the preparation of allergy immunotherapy provided from January 21, 2020.
You asked the Plan to waive the copayment for the preparation of allergy immunotherapy. You say that you were told that you would not owe anything. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for specialist services. You received the preparation of allergy immunotherapy on January 21, 2020. This is considered a specialist service. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for the preparation of allergy immunotherapy. The preparation of allergen immunotherapy falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the preparation of allergy immunotherapy provided from January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 31, 2020.
You asked the Plan to pay for the physician's services. You say that the provider's office told you that this visit would be covered after looking at your insurance card to confirm coverage. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services provided on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99309) provided on December 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON nursing facility care. You say that this service should be covered because the facility is in-network. The Plan denied your request. The Plan says this service was not authorized.
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 nursing facility care (99309) provided on December 2, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on February 13, 2020.
You asked the Plan to waive the copayment for the eye exam. You say that the diagnosis is incorrect. The Plan denied your request. The Plan says the copayment 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 $35 copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes. You have been asked to pay a $35 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show that a medical eye exam was performed. 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 eye exam provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient Coumadin clinic visit provided on February 19, 2020.
You asked the Plan to waive the copayment for the outpatient Coumadin clinic visit. You say that you cannot afford to pay $40 every month to have your pro-time tested. 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 $40 copayment for a Coumadin clinic visit. You have been asked to pay a $40 copayment for the outpatient Coumadin clinic visit. The outpatient Coumadin clinic visit falls within the "Outpatient hospital 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 the outpatient Coumadin clinic visit provided on February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 19, 2019 by a
non-network 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 a non-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 referring provider 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 medical services provided on December 19, 2019 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was 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 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 physician services provided on January 27, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive eye exam provided on January 28, 2020.
You asked the Plan to waive the copayment for the comprehensive eye exam. You say that this was an annual eye check-up and you should not have a copay. The Plan denied your request. The Plan says that the claim processed 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 $30 copayment for exams to diagnose and treat diseases and conditions of the eye by an Ophthalmologist. You have been asked to pay a $30 copayment for the comprehensive eye exam. The comprehensive eye exam falls within the exams to diagnose and treat diseases and conditions of the eye by an Ophthalmologist 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 comprehensive eye exam provided on January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on December 9, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the Plan should pay this claim. The Plan denied your request. The Plan says rules for telehealth services were not met.
The Plan must follow Medicare rules. Medicare 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 authorized 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. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on December 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement grafts (D7953) and guided tissue regenerations (D4266) provided on August 24, 2019.
You asked the Plan to pay for the bone replacement grafts and guided tissue regenerations. The Plan denied your request. The Plan says that these services are not covered by 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. Therefore, we decided that the Plan does not have to pay for the bone replacement grafts (D7953) and guided tissue regenerations (D4266) provided on August 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar. You asked the Plan to pre-approve a grab bar. You say that the enrollee needs these bars in order to avoid falling while taking a shower. You say that the enrollee is low mobility and has suffered falls in the past. You say that an exception for coverage should be made in this case because of medical necessity. The Plan denied your request. The Plan says grab bars are not a covered benefit. The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the gauze provided on January 22, 2020.
You asked the Plan to pay for the gauze. You say that the Plan should pay this claim. The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. Records show that the gauze was used in a SNF. The facility must furnish all necessary covered supplies to the beneficiary either directly or under arrangements made with outside providers. Theses supplies would have been included in the global payment submitted to the plan by the facility. Therefore, we decided that the Plan does not have to pay for the gauze provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 14, 2019 by an out of network provider.
You asked the Plan to pay for the medical services. You say that you did not receive the correct insurance information from the enrollee at the time of service. The Plan denied your request. The Plan says you did not request 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 the medical services provided on October 14, 2019 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ferric carboxymaltose or waive the
copayment for the administration of infusions provided on July 11, 2019 and July 18, 2019.
You asked the Plan to waive the coinsurance for the ferric carboxymaltose and waive the copayment for the
administration of infusions. You say that this is expensive and your bill is getting larger. The Plan denied your
request. The Plan says that cost share is a contractual obligation under the plan and cannot be waived.
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 each Medicare-covered Part B drug and a $275 copayment for Medicare-covered surgery or
other services provided to you at an outpatient hospital.
You have been asked to pay a 20% coinsurance for the ferric carboxymaltose and less than a $275 copayment
for the administration of infusions. The ferric carboxymaltose falls within the Medicare-covered Part B drug
benefit category and the administration of infusions falls within the Medicare-covered surgery or other services
provided to you at an outpatient hospital benefit category. This means that you have been asked to pay the
correct amount for the ferric carboxymaltose and less than the correct amount for the administration of
infusions 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 ferric carboxymaltose or waive the copayment for the administration of infusions provided on July 11, 2019
and July 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an Electrocardiogram (EKG) Interpretation (93010) provided
December 24, 2019.
You asked the Plan to pay for the EKG interpretation. You say that services were medically necessary and
billed correctly. The Plan denied your request. The Plan says the service can only be billed once per date of
service in the emergency room setting.
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 93010 is not supported in the medical record. Specifically, only one EKG interpretation
can be billed per service date in the emergency room. The amount billed exceeds the allowed amount. Based on
this information, we decided that Medicare rules for coverage of the EKG interpretation have not been met.
Therefore, we decided that the Plan does not have to pay for an Electrocardiogram (EKG) Interpretation
(93010) provided December 24, 2019.