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

We decided that the Plan does not have to pay for the medical services provided on July 1, 2019 by out ofnetwork provider. You asked the Plan to pay forout-of-network services.. You say that these services should be paid.The Plan denied your request. The Plan says these services were 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 forthe medical services provided on July 1, 2019 by out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on June 15, 2019.You asked the Plan to waive the copayment foran ambulance trip. You say that you met the MOOP and disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for ambulance services.You had an ambulance trip on June 15, 2019. The plan submitted evidence that your claims were reprocessed for 2019 bringing the amount you paid out-of-pocket to $3,455.00. Therefore, youare responsible to pay the $350 copayment.  You have been asked to pay a $350 copayment for an ambulance trip. An ambulance trip falls within the ambulance services benefit category. This means that you have been asked to pay the correct amount based onyour 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 foran ambulance trip provided on June 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have  the diabetic supplies coded as E2100, A4253, A4259, A4256 and A4258 provided. August 13, 2019 to November 1, 2019.You asked the Plan  the diabetic supplies. You say that say the medical records provided support the necessity of the service in dispute.The Plan denied your request. The Plan says the records do not support the items billed.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 proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid delivery ticket and proof of delivery for the supplies provided in this case. The delivery ticket submitted did not include the carrier's tracking number, and the proof of delivery did not include an order number or details to corroborate the delivery ticket submitted.  The proof of delivery is also not itemized to indicate the specific supplies;Therefore, we decided that the Plan does not have  the diabetic supplies coded as E2100, A4253, A4259, A4256 and A4258 provided. August 13, 2019 to November 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additional for the periodic evaluation (D0120), the cleaning
(D1110), the bitewing x-rays (D0274), the treatment planning (D9450), the resin-based fillings on tooth #'s 2
and 28 (D2392), or the extraction (D7210) provided from August 23, 2019 to October 3, 2019.
You asked the Plan to pay additional for the periodic evaluation (D0120), the cleaning (D1110), the bitewing xrays
(D0274), treatment planning (D9450), the resin-based fillings on tooth #'s 2 and 28 (D2392), and the
extraction (D7210). You say that you would like the procedure covered under your medical benefits for oral
surgery.
The Plan denied your request. The Plan says if you obtain covered services from an out-of-network provider,
then you pay the coinsurance amount multiplied by the Medicare payment rate for non-participating providers.
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 treatment planning (D9450), the
resin-based fillings on tooth #'s 2 and 28 (D2392), and the extraction (D7210) are not among those covered
under this benefit.
The periodic evaluation (D0120), the cleaning, (D1110), and the bitewing x-rays (D0274) were covered with
the 30% coinsurance amount multiplied by the Medicare payment rate from an out-of-network provider. The
record shows the provider is out-of-network.
Therefore, we decided that the Plan does not have to pay additional for the periodic evaluation (D0120), the
cleaning (D1110), the bitewing x-rays (D0274), the treatment planning (D9450), the resin-based fillings on
tooth #'s 2 and 28 (D2392), or the extraction (D7210) provided from August 23, 2019 to October 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approve a shower chair. You say that you disagree with the denial.The Plan denied your request. The Plan says the item is not covered.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair 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-approvea shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator rental provided from July 12, 2019 to July 19, 2019.
You asked the Plan to reimburse you for the rental. You say that you were told by a pulmonologist you would not be released from the hospital without an oxygen concentrator. The Plan denied your request. The Plan says the supplier is not certified by Medicare and there is no call history regarding durable medical equipment.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or provider who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider has opted out of the Medicare program. The file shows that the practice entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen concentrator rental provided from July 12, 2019 to July 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99314) provided on July 24, 2019 by out of network provider.You asked the Plan to pay foran office visit. You say that you are requesting a reconsideration of the denial because you say that your mother has been seeing the physician since the early 80's and was unaware she needed to have prior approval to see him. Due to your mother's advanced age, the physician has become her gerontologist. Since your mother never had to request prior approval and was not aware that payment should be reconsidered.The Plan denied your request. The Plan says the physician is not contracted with the member's health plan. The Plan contract states that care received from an out-of-network provider will not be covered unless it is emergency care or urgently needed care, and end-stage renal disease services. The claim does not meet the emergent or urgent criteria base on the codes submitted. The record shows that on March 16, 2109, your mother was sent a letter advising her primary care physician (PCP) was no longer in-network and this physician was assigned to be her PCP for medical care. There are network providers in your mother's area and sheis enrolled in an HMO plan with no 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 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 foran office visit (99314) provided on July 24, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the test provided on August 7, 2019.
You asked the Plan to waive the deductible for the Cologuard test. You say that you were not informed that the doctor used an out-of-network lab for the Cologuard processing. You say the test should be considered a preventive service. 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. Your contract with the Plan says that there is a $750 deductible that applies towards out-of-network laboratory work. The Cologuard test you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category out-of-network laboratory work. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies for out-of-network laboratory work. The allowed amount for the Cologuard test is $498.69. Therefore, $498.69 was applied to your $750 deductible.
This cost sharing is a contractual obligation that had not been met at the time the Cologuard test was received on August 7, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the Cologuard test provided on August 7, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physical therapy services provided from November 2, 2018 toNovember 30, 2018.You asked the Plan to pay forthe skilled nursing facility services. You say that the enrollee revoked their hospice benefit on November 1, 2018.The Plan denied your request. The Plan says the enrollee's claim would be coveredunder 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.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 November 1, 2018. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe physical therapy services provided from November 2, 2018 to November 30, 2018
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from May 31, 2019 to August 19, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). 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 the glucose monitor, test strips, lancets, control solution, and lancet device provided from May 31, 2019 to August 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided September
18, 2019.
You asked the Plan to pay for the periodontal maintenance (D4910). You say that your dentist recommends
you have periodontal maintenance every 3 months due to your severe periodontal disease. The Plan denied
your request. The Plan says the benefit limitation is exhausted.
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, there is a benefit limit for periodontal
maintenance (D4910). The plan clearly states that only two periodontal maintenance procedures are covered
every plan year. The records show the Plan paid for periodontal maintenance (D4910) procedures on February
5, 2019 and May 28, 2019, which exhausted the benefit. Therefore, we decided that the Plan does not have to
pay for the periodontal maintenance (D4910) provided September 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision care provided on September 10, 2019 by an out of
network provider.
You asked the Plan to pay for vision care. You say that you are contracted by the facility. You say that it is the
facility's responsibility to get prior authorization. The Plan denied your request. The Plan says the enrollee's
nursing facility is out-of-network. The Plan says that 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 vision care provided on September 10, 2019 by
out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray (code D0220), each additional intraoral periapical x-ray (code D0230 x2), and bitewings (code D0274) provided on July 1, 2019.You asked the Plan to pay forthe intraoral periapical x-rays and bitewings. You say that prior to your visit calls were made to the Plan to verify benefit coverage. You also say that no one specified to you or anyone in the provider's office what type of x-ray was covered.The Plan denied your request. The Plan says these services are not covered by the Plan. The Plan also says that their records do not support that you or the provider's office contacted the Plan prior to the services being rendered.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 forthe first intraoral periapical x-ray (code D0220), each additional intraoral periapical x-ray (code D0230 x2), and bitewings (code D0274) provided on July 1, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from July 23, 2019 to July 29, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 Plandid not pre-approve the servicesat 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 from July 23, 2019 to July 29, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing facility (SNF) services provided June 29, 2019 to July 28, 2019.You asked the Plan to pay forthe SNF services.. You say that you feel that the plan should cover for SNF services.The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.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 SNF services.. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
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 SNF services. have not been met.Therefore, we decided that the Plandoes not have to pay forskilled nursing facility (SNF) services provided June 29, 2019 to July 28, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from June 16, 2019 to June 18, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are unable to pay this amount. 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 $265 copayment for each day for days 1 to 8 for Medicare-covered hospital care.
You have been asked to pay a $265 copayment for each day of your inpatient hospital stay. ($265 x 2 days = $530). The inpatient hospital stay falls within the "Inpatient 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 inpatient hospital stay provided from June 16, 2019 to June 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four 2D oral/facial photographic images, oral hygiene instructions, and topical application of fluoride varnish provided on July 30, 2019.You asked the Plan to pay forthe 2D oral/facialphotographic images, oral hygiene instructions, and topical application of fluoride varnish. You say that you were not informed that these services were not covered by your insurance plan.The Plan denied your request. The Plan says these services arenot covered under your contract under any normal circumstances.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 forthe four 2D oral/facial photographic images, oral hygiene instructions, and topical application of fluoride varnish provided on July 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe mammogram on September 30, 2019.You asked the Plan to waive the copayment forthe mammogram. You say that you didn't need to have that procedure. You say that this shouldn't be your responsibility.The Plan denied your request. The Plan says the claim reprocessed to only apply a $10 copayment.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 $10 copayment after the deductible is met for each basic imaging service. You have been asked to pay a $10 copayment for the mammogram. The mammogram 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 copayment forthe mammogram on September 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from July 28, 2019 to August 2, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that there are several charges you disagree with and say did not take place. 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 $350 copayment for each Medicare-covered hospital stay. You have been asked to pay a $350 copayment for the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient 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 inpatient hospital stay provided from July 28, 2019 to August 2, 2019.