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

We decided that the Plan does not have to waive the coinsurance fordialysis provided from May 1, 2019 through May 31, 2019.You asked the Plan to waive the coinsurance fordialysis. You say that you paid a provider that should have been paid by the Plan. You say that you should be reimbursed.The Plan denied your request. The Plansays the coinsurance 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 20% coinsurance for Medicare-covered benefits.You have been asked to pay $694.64, which is less than the standard 20% coinsurance for dialysis because you met your maximum out-of-pocket. Dialysis falls within the "Services to Treat Kidney Disease" benefit category. The records show that prior to beginning dialysis treatments you had only met $4,205.36 of your maximum out-of-pocket. ($4,900 -$4,205.36 = $694.64).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 fordialysis provided from May 1, 2019 through May 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (code D0120) and complete series of intraoral x-rays (code D0210) provided on April 9, 2019.You asked the Plan to pay for the periodic oral evaluation and intraoral x-rays. You say that you went to the dental provider for a procedure and were told that your medical insurance would not cover the services.The Plan denied your request. The Plan says the limits for these services have already been reached.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, periodic oral evaluations (code D0150) are limited to once every 6 months per provider and complete series of intraoral x-rays (code D0210) are limited to once per provider every 36 months. The record shows that you received a periodic oral evaluation on December 17, 2018 and your periodic oral evaluation benefit is now exhausted. The record also shows that you received a complete series of intraoral x-rays on April 5, 2018, and your complete series of intraoral x-rays benefit is now exhausted.Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (code D0120) and complete series of intraoral x-rays (code D0210) provided on April 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on April 15, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on April 15, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pay forhyperthermia treatment provided on October 31, 2018.You asked the Planto pay forthe treatment. You say that this should be paid for.The Plandenied your request. The Plansaysthe enrollee self-directed to an out-of-network providerlMedicarerules 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 rendering 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 Plandoes not haveto pay forhyperthermia treatment provided on October 31, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by out of
network provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says there was no prior authorization obtained
for the services in question. The Plan says that the referring provider is also out-of-network.
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 medical services provided by out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 5, 2019 to September 13, 2019 by out of network provide.You asked the Plan to pay for psychotherapy visit. You say that you have been in-network with the Plan for many years.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and prior authorization was not 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 the medical services provided on April 5, 2019 to September 13, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the follow-up visits provided from January 16, 2019 to March 31, 2019 by the out of network providers.You asked the Plan to pay for the physician services. The provider says the enrollee was seen at hospital. The provider also says that the nursing facility is responsible for obtaining the necessary authorizations.The Plan denied your request. The Plan says the services were non-emergent and therefore required 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 providers in this case is not a network provider with the Plan. The rendering facility is not a network provider either. 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 follow-up visits provided from January 16, 2019 to March 31, 2019 by the out of network providers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on September 17, 2019.You asked the Plan to pay for the periodontal maintenance. You say that you require an extra cleaning for the prevention of the loss of teeth program that you are enrolled in. You also say that coverage should include the basic cleaning fee and costs that are to be paid by the enrollee.The Plan denied your request. The Plan says this service is not 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 for the periodontal maintenance provided on September 17, 2019.Your complaint about the discrimination of benefits is not a valid appeal for medical coverage. This part of 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on May 22, 2019.You asked the Plan to pay for the laboratory testing. 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.Review of the file shows that the ordering provider's progress notes were not provided to support the validity of this testing. The documentation therefore, does not support that the laboratory testing at issue in this appeal was not requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on May 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by out of network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation provided by the doctor.
You asked the Plan to pay for electrical stimulation. You say that you are appealing this denial. The Plan
denied your request. The Plan says the denial of payment for this service is correct, because this service is not
covered when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for electrical stimulation provided by the doctor.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a home sleep test (an HST) with a type III portable monitor (G0399) provided by out of network provider.
You asked the Plan to pay for an HST. You say that this provider is PAR and you have no copay for these services. You say that the sleep lab at the hospital is a participating provider per their sleep lab manager. You further say they verified coverage with the plan and were told there is no copay. The Plan denied your request. The Plan says you have no out-of-network benefits. The Plan also says that covered out-of-network services are those received for any of the following: emergency services, unforeseen out-of-geographic-service-area urgently needed services, routine travel dialysis, or services the plan has prior-authorized. (The principal reason for prior authorization for out-of-network care is for medically necessary services when those services cannot be obtained in network.) If none of these circumstances apply, neither the health plan nor Medicare covers out-of-network 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 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 a home sleep test (an HST) with a type III portable monitor (G0399) provided by out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on July 24, 2019 by out of network provider.You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says that there was no authorization for out of network 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 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 skilled nursing facility (SNF) services provided on July 24, 2019 by out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe fluoroscopic guidance for insertion, replacement or removal of central venousaccess device, sterile supplies, the introducer or sheath, non-laser, insertion of central venous catheter and implanted device, and port indwelling provided on August 26, 2019 by the out of network provider.You asked the Plan to pay forthe surgical services. The Plan denied your request. The Plan says the claim does not meet the urgent or emergent criteria for out of network services. The Plan says there is no evidence that any attempt was made to obtain authorization for the services. ThePlan also says the services can be provided in network.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 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 fluoroscopic guidance for insertion, replacement or removal of central venous access device, sterile supplies, the introducer or sheath, non-laser, insertion of central venous catheter and implanted device, and port indwelling provided on August 26, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental imaging (D0350) provided to the enrollee on May 22, 2019.
You asked the Plan to pay for the dental imaging. The Plan denied your request. The Plan says this is not a covered service.
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 service is not among those covered under this benefit. The plan covers only those dental services for which the codes are listed in the Member Handbook. The requested imaging, represented by code D0350, is not listed, and therefore is not covered. Therefore, we decided that the Plan does not have to pay for the dental imaging (D0350) provided to the enrollee on May 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lab services you received on April 30, 2019, and May 10, 2019.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you have never had a copayment for lab tests before.
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 Medicare-covered laboratory tests. Review of the file shows that you received two separate lab services on April 30, 2019, and May 10, 2019. You have been asked to pay a $20 copayment for each of the services, totaling $40. The services 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 copayment for the lab services you received on April 30, 2019, and May 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the LiftSeat Independence IV powered toilet seat provided by out of network provider.
You asked the Plan to reimburse you for the power toilet seat. You say that you had to purchase the lift seat because you have trouble getting up from the toilet. The Plan denied your request. The Plan says this is a convenience item not covered by Medicare or the Plan and the supplier is out-of-network.
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 reimburse you for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. Seat lift mechanism toilet is statutorily excluded by Medicare as not reasonable and necessary. 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. While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. We found no exception that would require the Plan to reimburse you for these items/services. Therefore, we decided that the Plan does not have to reimburse you for the LiftSeat Independence IV powered toilet seat provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by the out of network provider.
You asked the Plan to pay for the practitioner services. The Plan denied your request. The Plan says authorization was not obtained before the service was provided to the enrollee. The Plan also says that the service was not urgent or emergent.
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 provider in this case is not a network provider with the Plan. The facility is not a network provider either. 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 office visit provided by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copay for the ultrasound you received on July 24, 2019.
You asked the Plan to reduce the copay for the ultrasound. You say that the services were done at a clinic. The Plan denied your request. The Plan says the charge was applied based on your plan 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). Your contract with the Plan clearly says that you must pay an $85 copay for basic radiological services in an outpatient hospital.
The file shows that you received an ultrasound at a clinic. This clinic is considered an outpatient facility associated with a larger practice. You have been asked to pay an $81 copay for the ultrasound. Because the amount is less than the $85 copay, you were charged the lesser amount. The ultrasound falls 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 reduce the copay for the ultrasound you received on July 24, 2019.