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

We decided that the Plan does not have to waive the copayment for the hip replacement provided on January 15, 2020.
You asked the Plan to waive the copayment for the hip replacement. You say that the surgery wasn't done on this date. You say that you already paid a copayment for the actual surgery. 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 $400 copayment for outpatient surgery at an outpatient hospital facility. You have been asked to pay a $400 copayment for the hip replacement. The hip replacement falls within the "Outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that sedation was provided prior to the surgery being cancelled. 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 hip replacement provided on January 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits or waive the coinsurance for the triamcinolone acetonide and monovisc injections provided on April 15, 2019 and June 20, 2019.
You asked the Plan to waive the copayments for the office visits and waive the coinsurance for the triamcinolone acetonide and monovisc injections. The Plan denied your request. The Plan says that the cost sharing 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 $25 copayment for Physician/Practitioner services, including doctor's office visits in a specialist office and a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a $25 copayment for each office visit and a 20% coinsurance for the triamcinolone acetonide and monovisc injections. The office visits fall within the Physician/Practitioner services, including doctor's office visits in a specialist office benefit category and the triamcinolone acetonide and monovisc injections fall 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 copayments for the office visits or waive the coinsurance for the triamcinolone acetonide and monovisc injections provided on April 15, 2019 and June 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the monaural behind the ear hearing aid to be purchased
through the Provider
You asked the Plan to pre-approve the hearing aid. You say that you were in your shed and realized you were
unable to hear anything out of one hear and that you had lost your hearing aid. The Plan denied your request.
The Plan says hearing aids must be purchased through an in-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 hearing aids are covered when provided by a contracted provider. Prior authorization is
required for hearing aids costing more than $500.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to preapprove
the monaural behind the ear hearing aid to be purchased through the Provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheeled folding walker (E0143) and sales tax (S9999) purchased January 10, 2020.
You asked the Plan to pay for the walker and sales tax.. You say that you needed a new walker and needed the replacement quickly so you had your daughter order it from this provider. It was $50 less than any other provider. The Plan denied your request. The Plan says the items were purchased from a provider who is not contracted with the plan and is not certified for Medicare. Sales tax is not covered.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider and supplier enroll in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the walker and sales tax. have not been met. Therefore, we decided that the Plan does not have to pay for the wheeled folding walker (E0143) and sales tax (S9999) purchased January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services provided on November 27, 2019.
You asked the Plan to waive the copayment for physician services. You say that you didn't see your primary care physician after surgery. You say that only a nurse was there for a short time. 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 $20 copayment for each primary care doctor visit for Medicare-covered benefits. You have been asked to pay a $20 copayment for physician services. Physician services fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the services were to certify you for home health care. 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 physician services provided on November 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses purchased on October 11, 2019 from an out-of-network provider.
You asked the Plan to pay for the eyeglasses. You say that in the past your frames have been covered from the Provider. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. The provider is not in-network and your EOC clearly states, the Plan provide a $150 allowance once every 24 months for you to use toward the purchase price of eyewear from a plan optical facility when a physician or optometrist prescribes an eyeglass or contact lens for vision correction. Therefore, we decided that the Plan does not have to pay for eyeglasses purchased on October 11, 2019 from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased on July 8, 2019.
You asked the Plan to pay for the eyeglasses. You say that you purchased glasses last year from this Provider and received reimbursement without a problem. Now you're told last year was an exception but you were not informed of this situation. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-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 Eyeglasses or contact lenses and fitting at a network optical provider per calendar year or 2 pairs of select eyeglasses at no cost per year. We looked at the file and the Plan's rules. any benefits received at a non-network optical provider is excluded form coverage. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased on July 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearings aid purchased on February 20, 2019.
You asked the Plan to pay for the hearing aids. You say that you had lost one of your previous hearing aids and could not afford to pay for a replacement. The Provider provided documentation showing verification and approvals and they told you that you qualified. The Plan denied your request. The Plan says the maximum benefit has been exhausted.
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 Unlimited allowance for 2 hearing aids every 36 months. Records show that you received hearing aids on May 4, 2018. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearings aid purchased on February 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on August 14, 2019.
You asked the Plan to reimburse you for the hearing aids. You say that the hearing aids are far superior to much more expensive hearing aids and so you want to continue purchasing them from this provider. The Plan denied your request. The Plan says there is no coverage if hearing aids or related services are received from a provider not part of the plan's hearing aid vendor network.
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 ordered directly from hi HealthInnovations. We looked at the file and the Plan's rules. The requested provider in this case is not a network hearing aid provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on August 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on July 26, 2019.
You asked the Plan to reimburse you the hearing aids. You say that you belong to a PPO plan and the 2019 benefit sheet shows the Plan would pay something for hearing aids out-of-network. The Plan denied your request. The Plan says you must use a Plan  provider and this provider is not a Plan 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 you see a Plan  provider. We looked at the file and the Plan's rules. The file shows you provided a 2019 benefits document; however the document states "see detailed benefits for full Summary of Benefits". The Plan's Evidence of Coverage says that you must use a Plan provider to receive the benefit. This provider is not a covered provider. Therefore, we decided that the Plan does not have to reimburse you for the hearing aids provided on
July 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglass frames purchased from an out of network provider on December 5, 2019.
You asked the Plan to pay for the eyeglass frames. You say that the provider is close to your home and you wanted to get your glasses repaired quickly and you assumed the provider  would be approved for glasses repair because they are listed as an approved pharmacy. The Plan denied your request. The Plan says enrollee's must obtain vision services from a participating vision care 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 obtained from any participating vision care provider. We looked at the file and the Plan's rules. You must obtain routine vision services, including eyeglasses, from a participating vision care provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglass frames have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglass frames purchased from an out of network provider on December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive eye exam (92004) with refraction services (92015) provided on August 27, 2019.
You asked the Plan to pay for the vision services. You say that you were told at the provider that the services would be covered. The Plan denied your request. The Plan says this request exceeds the allowed benefit limit.
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 No referral is required for an annual routine eye exam, but you must use a provider in the Vision Care network.. We looked at the file and the Plan's rules. Based on a review of the file, routine vision services was provided on 7/18/2019. Therefore, the vision benefit limit has been exceeded and charges apply for services on 08/27/2019.
Based on this information, we decided that the Plan's rules for coverage of the vision services have not been
met. Therefore, we decided that the Plan does not have to pay for the comprehensive eye exam (92004) with
refraction services (92015) provided on August 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praulent injector pens
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee needs approval for this drug and cannot tolerate other medications. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. The Plan also says that the enrollee's commercial pharmacy benefits may be administered by another Provider.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Praulent injector pens
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit and eyeglasses purchased from the Provider on October 10, 2019.
You asked the Plan to pay for the eyeglasses and office visit. You say that this same claim was made 3 years ago with the same provider and this was covered to the allowable max. The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-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 There is a $150 allowance every 24 months to use towards the purchase price of eyewear from a plan optical facility. We looked at the file and the Plan's rules. For covered vision services you must use a plan optical facility for purchases of eyewear. This provider is not a network provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses and office visit have not been met. Therefore, we decided that the Plan does not have to pay for office visit and eyeglasses purchased on October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for opthalmological services (92014) and prescription fitting
(92310) provided by a non-CMS Assignment accepting provider.
You asked the Plan to pay for the opthalmological services and prescription fitting. You say that you would
like your claim to be resubmitted under the provider so that it can be paid. The Plan denied your request.
The Plan says this provider does not accept CMS-assignment so the Plan is not allowed under Medicare's rules
to reimburse for these services.
The Plan must follow Medicare rules. Medicare rules say that Medicare is not permitted to make payments for
services rendered by non-Medicare providers.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the opthalmological services and prescription fitting have not been met. Specifically, the record
indicates that this provider does not accept CMS-assignment. Therefore, we decided that the Plan does not have
to pay for opthalmological services (92014) and prescription fitting (92310) provided by a non-CMS
Assignment accepting provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on August 30, 2019.
You asked the Plan to pay for the hearing aids. You say that you were made aware, at the time of your fitting,
that the provider was not in your insurance network for 2019 but you didn't want to go anywhere else since they had
all your records from 2018 and you wanted the same type hearing aid and the same professional care you had
received in 2018. 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. The plan has partnered with another Provider to provide your hearing benefit.
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 provided by the other provider.
We looked at the file and the Plan's rules. The provider at issue in this appeal is not a network hearing aid
provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not
been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on August 30,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on November 5, 2019.
You asked the Plan to reimburse you for the hearing aids. You say that the same hearing aids you chose from the network provider was available at another provider for a lower price. The Plan denied your request. The Plan says that hearing aids purchased from an out of network/non-Plan provider is not a covered benefit under the terms of your Plan benefits.
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 purchased from a Plan provider or vendor. We looked at the file and the Plan's rules. The hearing aid provider at issue in this case is not a Plan provider or vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on November 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on October 25, 2019.
You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your request. The Plan says this provider has opted out of Medicare.
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 practitioner 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 by a provider that has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the services you received on October 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for wrist hand finger orthosis (L3808) provided on February 11, 2020 by an in-network provider.
You asked the Plan to waive the coinsurance for the DME. You say that you were not aware or informed that the wrist brace would have a significantly higher copayment. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a wrist hand finger orthosis (L3808) provided on February 11, 2020 by an in-network provider. You are asked to pay 20% coinsurance for the DME. 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 wrist hand finger orthosis (L3808) provided on February 11, 2020 by an in-network provider.