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 to the enrollee by an out-of-network provider on September 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chiropractic visit provided on October 11, 2019.
You asked the Plan to waive the copayment for the chiropractic visit. You say that you do not agree with the $50 not being paid on this claim. You say you would like the claim to be reprocessed and paid. The Plan denied your request. The Plan says that the claim was not denied and 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 $20 copayment for each out-of-network specialist office visit. You have been asked to pay a $20 copayment for the chiropractic visit. The chiropractic visit falls within the "Chiropractic services (Medicare-covered)" 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 chiropractic visit provided on October 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe lab testing provided on September 25, 2019.You asked the Planto pay forthe lab testing. You say that the results were provided to show that this testing was rendered.The Plandenied your request. The Plansaysthe POS code used on this lab is not appropriate for a lab which receives a sample from a doctor's office.The Plan must follow Medicare rules. Medicare rules say that labs must report the POS code that corresponds to the location in which the sample was collected.In this case, the enrollee and the physician's office are two hours from the lab's location. The sample was noted as taken on 9/25/2019 and was received by the lab the next day. This does not support the use of POS code 81 as it does not appear that this sample was taken by the lab directly.Therefore, we decided that the Plandoes not haveto pay forthe lab testing provided on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses (V2200 and V2020) provided on October 17, 2018.You asked the Plan to pay for the eyeglasses. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says standard glasses or contact lenses are only covered after cataract surgery.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.The services you asked the Plan to pay for are considered routine vision services or eyewear.Therefore, we decided that the Plan does not have to pay for eyeglasses (V2200 and V2020) provided on October 17, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Coolief radiofrequency ablation of the knee.
You asked the Plan to pre-approve the ablation. You say that this is medically necessary. The Plan denied your
request. The Plan says medical studies have not proven that this procedure is helpful for treatment of knee pain.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are 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 pre-approve the ablation. Our reviewer says that the
requested ablation is not considered medically reasonable and necessary in this case. Our physician reviewer
found this is an experimental and investigational procedure that is the subject of ongoing clinical trials.
Therefore, it is deemed not medically necessary or reasonable.
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 ablation have not been met. Therefore, we decided that the Plan does not
have to pre-approve Coolief radiofrequency ablation of the knee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe wellness visit on October 8, 2019.You asked the Plan to waive the deductible forthe wellness visit. You say that you were not told that your doctor was no longer in the network. You say this was your annual wellness visit and it should be free.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 the$975 deductibleapplies toan out-of-network PCP's office. The wellness visit you asked the Plan to waive the deductible for falls within the "Annual wellness visit" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $975 deductible that applies towards out-of-network PCP office visits. The record shows the provider is out-of-network.This cost sharing is a contractual obligation that had not been met at the timeThis 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 deductible forthewellness visit provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an eye exam and an electrocardiogram provided on August 27, 2019 and October 17, 2019.
You asked the Plan to waive the copayments for an eye exam and an electrocardiogram. You say that you 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 $25 copayment for eye exams. Your contract with the Plan also clearly says that you must pay a $50 copayment for non-radiological diagnostic procedures and tests. The medical records show that you received an eye exam that went beyond routine services on August 27, 2019. Therefore, you are responsible to pay the $25 copayment. You received an electrocardiogram on October 17, 2019. Therefore, you are responsible to pay the allowed amount of $16.50, which is less than the $50 copayment. The total amount you owe is: $41.50. You have been asked to pay the total amount of $41.50 for an eye exam and an electrocardiogram. An eye exam falls within the vision care benefit category. An electrocardiogram 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 copayments for an eye exam and an electrocardiogram provided on August 27, 2019 and October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered the enrollee on October 17, 2019.
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 procedure code 99190 is not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered the enrollee on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug provided on November 27, 2019.You asked the Plan to waive the coinsurance for the Part B drug. You say that you were never told there would be a charge for the medication. You say you already paid for copayment for the visit. 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 20% coinsurance for in-network Medicare covered Part B drugs and other Medicare covered items. You have been asked to pay $58.00 which 20% of the allowed amount for the Part B drug. The allowed amount is $290.00. ($290.00 x 20% = $58.00). The Part B drug falls within the "Medicare Part B prescription drugs" benefit category. The record shows the Part B drug is considered a separate service.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 Part B drug provided on November 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on November 14,
2019.
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 procedure code 27236 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 27236 is open treatment of femoral fracture, proximal
end, neck, internal fixation or prosthetic replacement.
We find that CPT code 27236 is not supported in the medical record. Specifically, the records do not support
that the services was performed on the left side. Based on this information, we decided that Medicare rules for
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the
services rendered to the enrollee on November 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased July 8, 2019. 
 
You asked the Plan to pay for the hearing aids. You say that you were not aware about using the TruHearing provider. You were in need of hearing aids so you went and got better ones and you feel the plan should help pay for the hearing aids. The Plan denied your request. The Plan says hearing aids are limited to TruHearing branded hearing aids. Hearing aids that are not TruHearing-branded hearing aids are not covered. 
 
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 contract says the benefit is limited to TruHearing's advanced and Premium hearing aids and you must see a TruHearing provider to use this benefit. 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 hearing aids purchased July 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 29, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 29, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on July 18, 2019.
You asked the Plan to waive the copayment for an ambulance trip. You say that you had no control over the
second ambulance trip and feel that you should not be responsible for 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 $150
copayment for ambulance services.
You have been asked to pay a $150 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 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 an ambulance trip
provided on July 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99309) and determination of refractive state (92015) on November 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for subsequent nursing facility care and determination of refractive state. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says the services were obtained from an out-of-network provider without prior authorization, therefore coverage criteria has not been met.
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 subsequent nursing facility care (99309) and determination of refractive state (92015) on November 5, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on November 20, 2019.
You asked the Plan to waive the copayment for an EGD. You say that you 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 outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You have been asked to pay a $350 copayment for an EGD. An EGD falls within the outpatient surgery,
including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for an EGD provided on November 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan
denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the enrollee is medically stable. There is no evidence of complex medical issues
that require monitoring by an inpatient physical medicine and rehabilitation physician three times per week or a
need for acute rehabilitation nursing care. While the enrollee may benefit from continuing physical and
occupational therapy, there is no evidence of a need for an intensive therapy program with therapy three hours
per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ALS emergency ambulance service provided September
17, 2019.
You asked the Plan to pay for the ambulance services. You say that you are appealing the denial of coverage.
You understand that SSS is your primary health plan and at least one of the transportation called was notified.
The Plan denied your request. The Plan says this plan is secondary to your group health plan.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has verified that
your Group Health Plan is the primary payer. As the secondary insurer, the Plan cannot be held responsible for
the ambulance services until the primary insurer has denied the claim for these services. Therefore, we decided
that the Plan does not have to pay for the ALS emergency ambulance service provided September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on October 21, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you do not want to pay this bill because it was just like all the other visits. You say the other visits were paid in full. 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 $30 copayment for each specialist visit. You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 specialist office visit provided on October 21, 2019.Our decision is only about the October 21, 2019 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.You asked the Plan to pre-approve massage therapy. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says massage therapy is not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist.Therefore, we decided that the Plan does not have to pre-approvemassage therapy.