Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on July 20, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received urgent care services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $65 copayment for Urgently needed services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received urgent care services on July 20, 2020. You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the Urgently needed services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the urgent care visit provided on July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve2 additional trips (A0100).

You asked the Plan to pre-approve the additional trips. You say that you have used all of your trips and you are requesting additional trips.The Plan denied your request. The Plan says the request for additional transportation is not covered under the plan benefits.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 10 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve 2 additional trips (A0100)
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 3, 2020.
You asked the Plan to pay for the ambulance services. You say that you did not request this service. 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 September 3, 2020. 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 provided on September 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered on July 24, 2020.
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 claims were billed incorrectly.
The Plan must follow Medicare rules. The rules say that Medicare requires all home health agency billing claims to be submitted on the Form CMS-1450 hard copy form. We looked at the file and Medicare rules. The file shows that the claim was not submitted on the CMS-1450/UB-04 form. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered on July 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 16, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that you would like reconsideration because it is the responsibility of the facility to obtain authorization. The Plan denied your request. The Plan says this service required prior authorization and none was obtained.
Medicare rules say that plans can require enrollees obtain authorization before receiving services. The contract with the Plan says that the Plan requires authorization for these services. 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 medical services provided on July 16, 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 crown (D2740) on tooth #5 and clinical crown lengthening (D4249) provided on January 21, 2020.
You asked the Plan to pay for the crown and clinical crown lengthening. You say that you were told you would not be charged, and proceeded to get the permanent crown. The Plan denied your request. The Plan says clinical crown lengthening is not a covered benefit. The Plan also says that the maximum allowed for the crown had been met.
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, clinical crown lengthening is not among those covered under this benefit. The contract clearly states that crowns are limited to once per tooth every five years. The record shows that you received a crown on tooth #5 on December 4, 2015, and your crown benefit for tooth #5 had been exhausted. Therefore, we decided that the Plan does not have to pay for the crown (D2740) on tooth #5 and clinical crown lengthening (D4249) provided on January 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a hearing aid check (92593) provided August 7, 2020.
You asked the Plan to pay for the hearing aid check. You say that the hearing aids check was medically necessary and has been covered before. The Plan denied your request. The Plan says this service is not covered because it was obtained from an out-of-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when obtained from plan contracted providers. We looked at the file and the Plan's rules. The record shows the hearing services were obtained out-of-network. Based on this information, we decided that the Plan's rules for coverage of the hearing aid check have not been met. Therefore, we decided that the Plan does not have to pay for a hearing aid check (92593) provided August 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for computed tomographic angriography, heart, coronary arteries and bypass graft (when present) with or without contrast material (75574) provided.

You asked the Plan to waive the co payment for Computed tomographic angiography. You say that balance billing in Texas is illegal. Please handle quickly. Provider is threatening collection action.The Plan denied your request. The Plan says the claim was processed and the correct co payment applied.

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 $325 copayment for CT scans. 

You have been asked to pay $$178.45 co payment for the computed tomographic angiography. The Medicare allowed amount is less than co payment amount therefore the $178.45 was applied. The computed tomographic angiography falls within the Outpatient diagnostic tests and therapeutic services and 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 co payment for computed tomographic angriography, heart, coronary arteries and bypass graft (when present) with or without contrast material (75574) provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a cardiovascular panel (81407, 81408, 81479) provided on June 5, 2020.
You asked the Plan to pay for a cardiovascular panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that policy denies coverage for all CV risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The testing at issue is not covered. Based on this information, we decided that Medicare rules for coverage of a cardiovascular panel have not been met. Therefore, we decided that the Plan does not have to pay for a cardiovascular panel (81407, 81408, 81479) provided on June 5, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forpractitioner services provided to the enrollee on June 24, 2020.You asked the Plan to pay forthis service. You say that this claim shouldbe paid.The Plan denied your request. The Plan says the Medicare website shows the enrollee was enrolled in hospice from April 10, 2020 through June 05, 2020. In accordance with Medicare guidelines, the provider needs to bill Original Medicare, using the proper modifiers, for services rendered on June 24, 2020. Per the regulations above, the member's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. It is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forpractitioner services provided to the enrollee on June 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 10, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 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 June 10, 2020. 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 provided on June 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on June 16, 2020. You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you should only be charged $325 for the biopsy. You should not be responsible for the mammogram copayment. 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 $45 copayment for each in-network Medicare-covered x-ray. You have been asked to pay a $45 copayment for the diagnostic mammogram. The diagnostic mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you received a screening mammogram on June 4, 2020 which makes the mammogram on June 16, 2020 a diagnostic mammogram. 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 mammogram provided on June 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (74220) provided July 16, 2020.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code shares a column I / column II relationship with another code billed.
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 74220 is not supported in the medical record. Specifically, CPT code shares a column I / column II relationship with code 74230 which was also billed. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (74220) provided July 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide non-emergency transportation.

You asked the Plan to provide non-emergency transportation. You say that you do not want to drive anymore and cannot find anyone to take you to medical appointments.The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of non-emergency transportation have not been met.Therefore, we decided that the Plan does not have to provide non-emergency transportation
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray (71045) provided on August 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an OON x-ray. You say that this denied in error. The Plan denied your request. The Plan says this 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 x-ray (71045) provided on August 1, 2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital physician service provided on July 14, 2020.
You asked the Plan to pay for physician service. You say that the enrollee's hospice status was revoked prior to admission. The Plan denied your request. The Plan says the denial of payment for this service is correct, because Original Medicare is responsible for coverage of benefits until the last day of the month in which hospice is revoked.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 8, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital physician service provided on July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided.

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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's 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 physician's services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter.
You asked the Plan to pre-approve the knee scooter. You say that you are scheduled for ankle surgery and have to be off of your feet for 6-8 weeks. The Plan denied your request. The Plan says the item in dispute is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare has determined that platform crutches will be denied as not medically necessary. A knee scooter is a type of platform crutch. Therefore, we decided that the Plan does not have to pre-approve a knee scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) provided June 11, 2020.
You asked the Plan to waive the copayment for the office visit. You say that as per your insurance, you should have been charged $5 copay. You trust it will be corrected and you will be billed $5 for your appointment. The Plan denied your request. The Plan says this claim processed and the correct copayment was applied per the Evidence of Coverage
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 $20 copayment for all other Medicare covered outpatient hospital services for Outpatient hospital services. You have been asked to pay $20 copayment for all other Medicare covered outpatient hospital services for the office visit. the office visit falls within the Outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) provided June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye exam rendered on June 10, 2020.
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 are not covered from a non-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when . We looked at the file and the Plan's rules. The file shows that you received services from a non-network provider. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the routine eye exam rendered on June 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Part B injectable drug provided from June 4, 2020, to June 18, 2020.
You asked the Plan to waive the coinsurance for the Part B injectable drug. You say that you were led to believe this medication was 100% covered. You say you are on a fixed income and this amount is a hardship. 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 20% coinsurance for all other in-network drugs covered under Medicare Part B. You have been asked to pay $826.20 which is 20% of the allowed amount for the Part B injectable drug on each date of service. The allowed amount is $4,131.00. ($4,131.00 x 20% = $826.20). ($826.20 x 3 dates of service = $2,478.60).
The Part B injectable drug falls within the "Medicare Part B prescription drugs" 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 Part B injectable drug provided from June 4, 2020, to June 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 22, 2020.
You asked the Plan to pay for the ambulance services. You say that you did not request for this service. 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 July 22, 2020. 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 provided on July 22, 2020.