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

We decided that the Plan does not have to pay forout of network physician services provided to the enrollee on August 6, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out-of-network care.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 providerin 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 thePlan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forout-of-network physician services provided to the enrollee on August 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Pride Jazi 600 power wheelchair (PWC).You asked the Plan to pre-approvethese services. You say that the PWC will help with personal activities outside of your home.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Althoughthis item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea Pride Jazi 600 power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Medi Alert Life Alert System (A9280).

You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or by Medicare.

The Plan must follow Medicare rules. Medicare rules say that alert systems are not covered because they are emergency communication systems that do not servea diagnostic or therapeutic purpose.

 While an alert system 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-approve a Medi Alert Life Alert System (A9280).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lens, polycarbonate (V2784), progressive lens (V2781), antireflective
coating per lens (V2750) and deluxe lens feature (V2702) provided on June 26, 2020.
You asked the Plan to pay for polycarbonate lens, progressive lens, anti-reflective coating per lens and deluxe
lens feature. You say that you tried to cancel the order and should not have to pay. The Plan denied your
request. The Plan says the items are not covered 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. The Plan covers standard contact lenses, eyeglasses, single vision or lined multi-focal lens and frame.
We looked at the file and the Plan's rules. You received enhanced eyewear. Based on this information, we
decided that the Plan's rules for coverage of polycarbonate lens, progressive lens, anti-reflective coating per
lens and deluxe lens feature have not been met. Specifically, only standard eyewear is covered by the plan; any
enhancement is the responsibility of the member. Therefore, we decided that the Plan does not have to pay for
lens, polycarbonate (V2784), progressive lens (V2781), anti-reflective coating per lens (V2750) and deluxe
lens feature (V2702) provided on June 26, 2020.
Your complaint potentially trying to cancel the items 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the remaining cost for the myocardial perfusion imaging, echocardiography, external ECG recording, technetium tc-99m and regadenoson injection provided on April 28, 2020.
You asked the Plan to waive the remaining cost for the myocardial perfusion imaging, echocardiography, external ECG recording, technetium tc-99m and regadenoson injection. You say that you paid a $45 copayment. You say that this amount is excessive, and you cannot pay it. The Plan denied your request. The Plan says the cost share 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 $150 copayment for each Medicare-covered radiological diagnostic service, a$20 copayment for Medicare-covered non-radiological diagnostic services, 20% coinsurance for each Medicare-covered medical supply and 20% coinsurance for each Medicare-covered Part B drug.
You have been asked to pay a total of $391.76 for the myocardial perfusion imaging, echocardiography, external ECG recording, technetium tc-99m and regadenoson injection.
Service
Allowed Amount
Standard Cost
Member Liability
Myocardial Perfusion Imaging
$330.84
$150
$150
Echocardiography
$170.25
$150
$150
External ECG Recording
$70.90
$20
$20
Technetium TC-99M
$121.70
20%
$24.34
Regadenoson Injection
$237.12
20%
$47.42
TOTAL:
$391.76
The myocardial perfusion imaging, echocardiography, external ECG recording, and technetium tc-99m fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The regadenoson injection falls within the "Medicare Part B Prescription Drugs" benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the remaining cost for the myocardial perfusion imaging, echocardiography, external ECG recording, technetium tc-99m and regadenoson injection provided on April 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on August 12, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you would like to be reimbursed $117.50. The Plan denied your request. The Plan says these services were performed by a non-participating provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.
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, you are responsible for a 50% coinsurance for services that are provided OON. You are also responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on August 12, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a follow-up office visit provided by a participating provider on October 1, 2020.You asked the Plan to waive the copayment foran eye exam office visit. You say that you do not feel like you should have to pay for this because you had to cancel the first one due to Covid-19. 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 $50 copayment for vision care/Medicare-covered visit. You have been asked to pay a $50 copayment for an eye exam office visit. Follow-up office visits are subject to copayments; therefore, the correct copayment has been applied. An eye exam office visit falls within the vision care/Medicare-covered visit 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 a follow-up office visit provided by a participating provider on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 25, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the 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 networkproviders available who can provide 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 forthe medical services provided to the enrollee by an out-of-network provider on August 25, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services (D0367) provided to you on February 3, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is not a covered benefit.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 services are not among those covered under this benefit. The Plan covers only those dentalcodes listed in the Evidence of Coverage. Code D0367 is not listed, and therefore is not covered. Please note that the records do not show that you have any liability for codes D0120 and D0330.Therefore, we decided that the Plan does not have to pay forthe dental services (D0367) provided to you on February 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the prostate resection provided on July 27, 2020 and the bone imaging and MRI provided on August 10, 2020.
You asked the Plan to waive the coinsurance for the prostate resection, bone imaging and MRI. You say that you decided on a plan that covers 100% of your bills but the Plan is only paying 80%. You say that you have accumulated thousands of dollars of debt due to this error. The Plan denied your request. The Plan says 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 surgery services at an in-network outpatient hospital and 20% coinsurance for advanced imaging services and nuclear medicine services at an in-network outpatient hospital. You have been asked to pay a total of $1,096.82 for the prostate resection, bone imaging and MRI.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
July 27, 2020
Prostate Resection
$4,246.23
20%
$849.25
August 10, 2020
Bone Imaging
$369.40
20%
$73.88
August 10, 2020
MRI
$868.44
20%
$173.69
TOTAL:
$1,096.82
The prostate resection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The bone imaging and MRI fall 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 coinsurance for the prostate resection provided on July 27, 2020 and the bone imaging and MRI provided on August 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on September 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 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 lab work provided on September 4, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you had on July 31, 2020.
You asked the Plan to waive the copayment for the lab services. You say that you believe there was an error with the lab test, so you shouldn't have to pay this charge. The Plan denied your request. The Plan says this copayment was charged 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 $5 copayment for diagnostic lab services. You have been asked to pay a $5 copayment for the lab services. This copayment applies even if you are not satisfied with the services you receive. 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 lab services you had on July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe moderate sedation services coded 99152 and 99153 provided on June 25, 2020.You asked the Plan to pay forthe moderate sedation 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 99152 and 99153 are not supported in the medical record. Specifically, thedocumentation submitted does not include the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; therefore, code 99152 is not supported. Code 99153 has a PC/TC indicatorof 3, for a technical component only code. As CPT code 99153 is a technical component only code, it should be reported by a MAC Part A or B hospital setting
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy rendered on February 24, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy rendered on February 24, 2020.Benefits for these servicesmay be available under Medicare Part D.Contactthe 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 pre-approve 10 additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that you have multiple medical appointments to 6 providers for several medical conditions. The Plan denied your request. The Plan says this request exceeds the benefit frequency limitations. Transportation above the benefit maximum of not covered.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way transportation trips per calendar year trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 10 additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical extraction provided on October 6, 2020.You asked the Plan to pay forthe surgical extraction. You say that you should have a $500.00 annual benefit for dental work.The Plan denied your request. The Plan says this service is not covered under your dental plan.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 surgical extraction provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic procedures provided on April 26, 2019.
You asked the Plan to pay for diagnostic procedures. You say that your records indicate that the claim was filed timely. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this claim was not submitted within the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for diagnostic procedures was not filed until August 3, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for diagnostic procedures provided on April 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forinfectious agent detection testing (87631) provided on April 21, 2020.You asked the Plan to pay forlab test. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of payment for this test is correct, because this testing is not covered.The Plan must follow Medicare rules. Medicare rules say that lab code 87631 is only covered when billed in places of service 20, 21, or 23. We looked at the file and Medicare rules. This lab test was billed in place of service 81 (independent laboratory), which is not a covered place of service for this lab code. Based on this information, we decided that Medicare rules for coverage of lab test have not been met.Therefore, we decided that the Plan does not have to pay forinfectious agent detection testing (87631) provided on April 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foroffice visit (99204) and Determination of refractive state (92015) provided on September 3, 2020.You asked the Plan to pay foroffice visit and eye refraction. You say that it has been over a year since you had your last eye exam and that you are allowed one a year.The Plan denied your request. The Plan says the $35 specialist copayment has been applied correctly and routine eye exams are only covered when provided in-network.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 with a $35 copayment for specialist visits and eye refractions must be obtained by the Plan's network optical providers.
We looked at the file and the Plan's rules. There is a $35 copayment for specialist visits and you went out-of-network for your eye refraction. Based on this information, we decided that the Plan's rules for coverage of office visit and eye refraction have not been met.Therefore, we decided that the Plan does not have to pay foroffice visit (99204) and Determination of refractive state (92015) provided on September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and bitewings (D0274) provided on August 17, 2020.
You asked the Plan to pay for the first intraoral periapical x-ray and bitewings. You say that your dental insurance allows for x-rays to be taken once per year. You also say that having less images taken at a reduced cost should not justify denying payment. The Plan denied your request. The Plan says these services are not covered.
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 first intraoral periapical x-ray (D0220) and bitewings (D0274) provided on August 17, 2020.