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

We decided that the Plan does not have to waive the copayment for the office visit provided on January 28,
2021.
You asked the Plan to waive the copayment for the office visit. You say that you were advised by the
receptionist you would not have a copayment charge because this was a follow up visit. You say that you want
to appeal the charge for $35. 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 $35
copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes.
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Vision care"
benefit category. There is no provision in the contract which indicates a copayment would be waived for
follow-up visits. 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 office visit provided on
January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle lite glucose monitor test strips.

You asked the Plan to pre-approve the Freestyle lite test strips. You say that the Freestyle lite glucose monitor gives you successful control of The Plan denied your request. The Plan says Accu-Chek is the preferred brand of test strips in your plan. The Accu-Chek strips and reader work like your current meter.

Medicare rules say that plans can require enrollees to get care from preferred providers. 

The requested provider in this case is not a preferred provider with the Plan. Accu-Chek is the preferred brand of test strips. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve Freestyle lite glucose monitor test strips.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided from January 2, 2020, to January 21,
2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was
submitted after 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 the services was not filed until March 2, 2021. 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 the services provided from January 2, 2020, to January 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and
prophylaxis provided on January 25, 2021 by an OON provider.

You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you
would like these services to be covered. The Plan denied your request. The Plan says these services were
rendered by a provider who is not under contract with the health 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
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic
oral evaluation, bitewing x-rays, and prophylaxis provided on January 25, 2021 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided from February 1, 2021 to February 8, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 had network providers available who could have provided 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 drug testing provided from February 1, 2021 to February 8, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractor office visit provided on January 14, 2021.

You asked the Plan to pay for the chiropractor office visit. You say that the initial appointment with the chiropractor was to plan a course of action. The Plan denied your request. The Plan says Medicare does not cover non-manipulative services provided by chiropractors.

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 the chiropractor office visit provided on January 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory work provided on February 8, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 laboratory work provided on February 8, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 14, 2020.

You asked the Plan to waive the copayment for the office visit. You say that this was an annual physical and you should pay a $0 copayment for the visit. 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 $10 for each covered visit or consultation in an outpatient location with your PCP or other primary care provider.

You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show the office visit was for abdominal pain and a follow up for blood pressure medication. 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 office visit provided on December 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider from June 9, 2020, to July 1, 2020.

You asked the Plan to pay for the 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 had network providers available who could have provided 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 services provided by an out-of-network provider from June 9, 2020, to July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for presumptive drug tests (80307) definitive drug tests (G0481)
provided on December 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that this plan follows Medicare billing
guidelines which do not require prior authorization for this test. You would request review the plan review this
appeal and attached supporting documents to process the claim towards payment. The Plan denied your
request. The Plan says enrollee's must receive their medical services from an in-network provider with the
exception being urgent or emergent services. Non-emergent services with non-contracted providers require
prior authorization before services being rendered.
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 had network providers available who could have provided 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 presumptive drug tests (80307) definitive drug tests (G0481) provided on December 10, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the deductible for ophthalmology services provided on January 4, 2021.
You asked the Plan to waive the deductible for ophthalmology services. You say that you should only owe a
copayment and disagree with the deductible charges for the eye exam. The Plan denied your request. The Plan
says that 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. Your
contract with the Plan says that the $750 deductible does not apply to in-network specialist services. Your
contract with the Plan also says that enrollee's must pay a $35 copayment for specialist services furnished in a
physician's office, ambulatory surgical center or hospital outpatient department.
The record shows that you received ophthalmology services at an in-network providers office on January 4,
2021. Ophthalmology services are considered specialist services. Your contract with the Plan says that the $750
deductible does not apply to in-network specialist services. Furthermore, there is no evidence on the claim
submitted by the provider of an outpatient hospital facility charge. Therefore, you cannot be asked to pay a
deductible for the in-network specialist services you received.
The Plan says you must pay a $750 deductible for ophthalmology services. Based on the Plan contract,
however, you cannot be asked to a $750 deductible for in-network specialist services. Therefore, we decided
that the Plan has to waive the deductible for ophthalmology services provided on January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 power scooter.

You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your
request. The Plan says there has been no evaluation of the home or evaluation of ability to operate the device.

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 scooter. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no documentation of a personal mobility deficit that impairs participation in mobility-related
activities of daily living, such as a toileting, feeding, grooming, and bathing in customary locations within the
home. There is no documentation that this deficit could not be helped by a walker or manual wheelchair. Based
on the medical records provided, there is no documentation you would be able to safely operate a power
mobility device.

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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 1 power scooter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasounds (CPT code 76642)
performed on February 10, 2021, and February 22, 2021.

You asked the Plan to waive the copayment for the breast ultrasounds. You say that you are appealing your
cost-share responsibility due to financial hardships. The Plan denied your request. The Plan says the claim was
processed accordingly with your 2021 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 breast ultrasound on February 10, 2021, and February 22, 2021.
The Medicare-allowed amount for the ultrasounds are less than the set $100 copayment; therefore, you have
been asked to pay the lesser amount of $93.93 per date of service for the ultrasounds. 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 breast ultrasounds (CPT code 76642) performed on February 10, 2021, and February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for parenteral nutrition services.

You asked the Plan to pay for parenteral nutrition services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the request is missing necessary documentation required for coverage.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file shows that the proof of delivery did not include an itemize order form or invoice to indicate the specific supplies; therefore, the billed supply code cannot be verified. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for parenteral nutrition services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that no skilled therapy or skilled nursing needs are identified.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for SNF services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for non-Medicare covered eyewear (V2799), provided on June
6, 2020.

You asked the Plan to pay for non-Medicare covered eyewear. You say that the item should be covered at a higher allowance. The Plan denied your request. The Plan says you have received the maximum allowed per your benefit Plan.

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 a $75 allowance for non-Medicare covered eyeglasses per a calendar year. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of eyewear have not been met. Specifically, you have received the allowed benefit amount for this item and, are therefore, responsible for the remaining amount. Therefore, we decided that the Plan does not have to pay for non-Medicare covered eyewear (V2799), provided on June 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on November 9, 2020.

You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the orthosis is not medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the lumbar-sacral orthosis (L0650). Our reviewer says that the orthosis is not medically necessary. Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible physical examination of the back.

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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services provided on October 31, 2020.

You asked the Plan to pay for moderate sedation services (99153) with place of service 23. You say that the Plan should pay this claim. The Plan denied your request. The Plan says CPT code 99153 may not be paid if furnished to a hospital inpatient or patients in a hospital outpatient department.

The Plan must follow Medicare rules. Medicare rules say that when completing the 1500 claim form, providers must enter the correct Place of Service (POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. 

In this case, code 99153 cannot be paid as billed due to an error with the POS code reported. Medicare billing criteria are not met. Therefore, the Plan does not have to pay for moderate sedation services provided under code 99153 on October 31, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
April 28, 2020.
You asked the Plan to pay for this 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 out of network physician services provided to the enrollee on April 28, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided from May 16, 2019, to May 18, 2019.
You asked the Plan to waive the copayment for emergency room visit. You say that you have a limited income and do not have money to pay this copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $50 copayment for emergency room visit. You have been asked to pay $50 copayment for emergency room visit. Emergency room visit falls within the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided from May 16, 2019, to May 18, 2019.