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

We decided that the Plan does not have to pre-approve office visits (99213 x 3) to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Additionally, the Plan has advised that translation services are offered for services obtained from an in-network provider. Therefore, we decided that the Plan does not have to pre-approve office visits (99213 x 3) to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary immediate denture and three additional extractions provided on February 8, 2021.

You asked the Plan to pay for the maxillary immediate denture and additional extractions. You say that your dentist contacted you stating your plan had changed, which you did not do. You also say that you cannot afford to pay these charges. The Plan denied your request. The Plan says the maxillary immediate denture is not a covered service. The Plan also says that your extractions benefit has 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, maxillary immediate denture is not among those covered under this benefit. The contract says that extractions are limited to one procedure code per calendar year. The record shows that you received five extractions on February 8, 2021, two of which were covered by the Plan, and your extractions benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the maxillary immediate denture and three additional extractions provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 provided on September 16, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 are not supported in the medical record. Specifically, the place of service on the CMS- 1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 provided on September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided by a participating provider on December 15, 2020.

You asked the Plan to waive the copayment for vision services. You say that this was a glaucoma screening. You say that you would like your $45 refunded. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for vision care. 

You have been asked to pay a $45 copayment for vision services. The correct copayment has been applied to the services that were provided. Vision services fall within the vision 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 vision services provided by a participating provider on December 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for tear duct surgery provided on November 9, 2020.
You asked the Plan to waive the copayment for outpatient surgery. You say that you should only have to pay $40 for this visit. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $265 copayment for outpatient surgery at an outpatient hospital. You have been asked to pay the allowed amount of $195, which is less than the $265 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 tear duct surgery provided on November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on April 15, 2021.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. 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 $45 copayment for in-network specialist's office services.

Review of the file shows that you received specialist services on April 15, 2021. You have been asked to pay a $45 copayment for these services. These services fall within the in-network specialist's office 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 specialist services rendered on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 13, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says 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 had network providers available who could have provided the services at issue in this appeal. 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 the services provided by an out-of-network provider on April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames and lenses received on December 14, 2020.

You asked the Plan to pay for frames and lenses. You say that you want the Plan to pay for these items. The Plan denied your request. The Plan says you are not covered for this service when services are rendered by an
out-of-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 an in-network provider is utilized. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of frames and lenses have not been met. Specifically, services were provided by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for frames and lenses received on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit and Part B drug injection you
received on February 22, 2021.

You asked the Plan to waive the cost share. You say that you did not agree to the injection. The Plan denied
your request. The Plan says you are responsible for the cost share.

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 Medicare Part B prescription drugs.

Review of the file shows that you had a specialist visit and were provided a Part B injection on February 22,
2021. You have been asked to pay a 20% coinsurance for the Part B drug services. You have also been asked to
pay a $25 copayment for the specialist visit. 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 cost share for the office visit and Part B drug injection you received on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulatory infusion pump coded E0781 and the infusion
supplies coded A4222 provided on February 22, 2021 and March 18, 2021.

You asked the Plan to pay for the ambulatory infusion pump and the infusion supplies. You say that you feel
these services should be covered. The Plan denied your request. The Plan says the date range submitted is not
allowed for the date span 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 codes E0781 and A4222 are not supported in the medical record. Specifically, the infusion
supplies were billed on dates of service February 22, 2021 and March 18, 2021. The date range submitted is not
allowed for the date span billed. Multiple months cannot be billed on one claim.

Based on this information, we decided that Medicare rules for coverage of the ambulatory infusion pump and
the infusion supplies have not been met. Therefore, we decided that the Plan does not have to pay for the
ambulatory infusion pump coded E0781 and the infusion supplies coded A4222 provided on February 22, 2021
and March 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the x-rays provided on February 22, 2021.

You asked the Plan to waive the copayments for the x-rays. You say that you pay a pretty good premium for the plan so you shouldn't have copayments for x-rays. The Plan denied your request. The Plan says you were charged the copayments 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 20% coinsurance for Outpatient Diagnostic Tests. 

You have been asked to pay 20% coinsurance for the x-rays. The x-rays fall within the Outpatient Diagnostic Tests 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 copayments for the x-rays provided on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) suspension sleeve (L2397) provided March 15, 2021.

You asked the Plan to pay for the orthosis. You say that please see attached documentation. Be advised that this enrollee requested services utilizing access to telemedicine from the physician of their choice in an effort to address COVID-19 concerns. The Plan denied your request. The Plan says the provider is not a Medicare certified DME supplier. There is no evidence of an established relationship between the enrollee and the ordering physician as required per CMS guidelines.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) suspension sleeve (L2397) provided March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the specialist office visit provided on January 28, 2021 by an
out-of-network provider.

You asked the Plan to pay for the specialist office visit. You say that the visit was needed in order to evaluate
the enrollee's current medical condition. The Plan denied your request. The Plan says the enrollee does not
have out-of-network benefits.

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 service 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
the service. Therefore, we decided that the Plan does not have to pay for the specialist office visit provided on
January 28, 2021 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device and accessories (E1007, K0861, E2620, E2311).

You asked the Plan to pre-approve the power mobility device and accessories. You say that the power
wheelchair is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been
met.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

The file shows that you cannot safely operate the PMD being requested. The record shows the ramp available
to the enrollee is unsuitable for the power wheelchair at issue. Modifications are needed to the enrollee's home
before the power wheelchair can be safely operated.

This means that Medicare rules for coverage of a PMD have not been met. Since the power wheelchair is noncovered,
the accessories are not eligible for coverage. Therefore, we decided that the Plan does not have to preapprove
a power mobility device and accessories (E1007, K0861, E2620, E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on July 22, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says services rendered by non-participating 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 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 office visit services provided to the enrollee on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the debridement provided on January 5, 2021.

You asked the Plan to waive the copayment for debridement (11042). You say that you were not informed the copayment would be $250. The Plan denied your request. The Plan says you were charged this copayment 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 $250 copayment for Outpatient Surgery at a hospital facility. 

You have been asked to pay a $250 copayment for debridement. The debridement falls within the Outpatient Surgery at a 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 debridement provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent observation care provided on March 12, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent observation care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 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 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 the subsequent observation care provided on March 12, 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 lumbar-sacral orthosis provided on September 28, 2020.

You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation indicates that the items rendered are not necessary for the treatment of the enrollee's condition.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on February 3, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that you did not get to see the doctor who you made the appointment to see. The Plan denied your request. The Plan says you were seen at a specialist office and charged this copayment 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 $45 copayment for Physician/Practitioner services, Specialist's Office. 

You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the Physician/Practitioner services, Specialist's Office 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 specialist office visit provided on February 3, 2021.

Please note, your complaint is not a valid appeal for medical coverage. Your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.