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

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on April 10, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that this ambulance ride was necessary to get you home from the hospital and that you should not owe anything beyond the standard payment. The Plan denied your request. The Plan says that 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 $325 copayment for each covered, one-way ambulance trip by ground or water. You have been asked to pay less than a $325 copayment for the ambulance transport. The ambulance transport falls within the covered, one-way ambulance trip by ground or water benefit category. This means that you have been asked to pay less than 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 ambulance transport provided on April 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on August 28, 2019.
You asked the Plan to waive the coinsurance for the Part B injection. You say that you have never had a copayment before for this injection. 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 Medicare Part B covered drugs at an in-network PCP's office, specialist's office, or pharmacy. You have been asked to pay $229.20 which is 20% of the allowed amount for the Part B injection. The allowed amount is $1,146. ($1,146 x 20% = $229.20). The Part B 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 coinsurance for the Part B injection provided on August 28, 2019.
Our decision is only about the August 28, 2019 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lens fitting (V2599) provided August 14, 2019.
You asked the Plan to pay for the vision services. You say that you request reconsideration as your doctor has submitted that the custom fitting was medically necessary to obtain vision and you will need this yearly The Plan denied your request. The Plan says contact lens fitting is not covered under the plan 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 these services when The plan covers one pair of eyeglasses or contact lenses after each cataract surgery.. We looked at the file and the Plan's rules. [Insert determination explanation]. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for contact lens fitting (V2599) provided August 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee by an out-of-network provider on August 9, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee by an out-of-network provider on August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 21, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 physician's services provided on August 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on September 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for pathology services. You say that you would like this reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these services. 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 pathology services provided on September 9, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 15, 2019 to September 13, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services that the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate setting other than a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 15, 2019 to September 13, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the periodic oral evaluation (D0120), the prophylaxis (D1110), and the bitewing x-rays (D0274) provided on November 14, 2019 by an out of network provider.
You asked the Plan to pay for the dental services. You say that you found this provider online. The Plan denied your request. The Plan says that dental services provided out of network are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a full copy of the applicable Evidence of Coverage for this case. We asked for this document but it was not provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Therefore the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the periodic oral evaluation (D0120), the prophylaxis (D1110), and the bitewing x-rays (D0274) provided on November 14, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular procedures provided on August 7, 2019 by an out of network (OON) provider.
You asked the Plan to pay for cardiovascular procedures. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained 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 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 cardiovascular procedures provided on August 7, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for needle, sterile, any size, each, provided on April 22, 2019.
You asked the Plan to pay for needle, sterile, any size, each (A4215). You say that The Plan denied your request. The Plan says submit the needle claim to Prescription Drug Plan.
This code cannot be paid as a separate line item. Therefore, we decided that the Plan does not have to pay for needle, sterile, any size, each, provided on April 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive the coinsurance for a Medicare Part B drug provided on October 18, 2019.You asked the Plan to waive the copayment for a specialist visit and to waive the coinsurance for a Medicare Part B drug. 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 $35 copayment per specialist visit. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a specialist visit on October 18, 2019. Therefore, you are responsible to pay the $35 copayment. You received a Medicare Part B drug on October 18, 2019. The allowed amount is $1,760.85 and 20% of that is $352.17. The total amount you owe is: $387.17.You have been asked to pay the total amount of $387.17 for a specialist visit and a Medicare Part B drug. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. A Medicare Part B drug falls within theMedicare 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 copayment for a specialist visit and does not have to waive the coinsurance for a Medicare Part B drug provided on October 18, 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 10, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you should not be charged because you just had a conversation and told to come back on a later day. 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 $45 copayment per visit for a specialist office visit. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits"benefit category. The medical record shows you were seen for a repeat evaluation.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 youenrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe specialist office visit provided on October 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation with an oral surgeon.You asked the Plan to pre-approve the dental service. You say that you are suffering from dry mouth and tooth decay. You also say that you want to know what is causing your dry mouth.The Plan denied your request. The Plan says the service you requested is not medically necessary.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approve a consultation with an oral surgeon.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora chest x-ray (71046) and an outpatient clinic visit (G0463) provided on August 29, 2019.You asked the Plan to pay for the x-ray and clinic visit. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not emergent or preauthorized. The enrollee has no out-of-network benefits. Preoperative x-rays in the absence of any signs or symptoms are not covered under Medicare rules.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 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 fora chest x-ray (71046) and an outpatient clinic visit (G0463) provided on August 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for destruction by neurolytic agent (64636) provided on October 31, 2019.You asked the Plan to pay for the destruction by neurolytic agent. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 64636 has been billed without an appropriate primary procedure.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 code 64636 is not supported in the record. Specifically, per Medicare, 64636 is a Type I add-on code. This means that 64636 must be billed with the appropriate primary procedure code. The record does not indicate that 64636 was billed with the appropriate primary procedure. Based on this information, we decided that Medicare rules for coverage of the destruction by neurolytic agent have not been met. Therefore, we decided that the Plan does not have to pay for destruction by neurolytic agent (64636) provided on October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on April 22, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe drug testing rendered on April 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture and mandibular partial denture.You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that you really need the dentures. You also say that you are unable to eat.The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says that you received this service less than 60 months ago.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, dentures are limited to one set every 5 years. The record shows that you received a mandibular partial denture on September 24, 2018 and a complete upper denture on October 9, 2018 and your dentures benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture and mandibular partial denture.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for routine transportation trips.You asked the Plan to pre-approve additional mileage for routine transportation trips. You say that the additional mileage is needed.The Plan denied your request. The Plan says the requested additional mileage exceeds the benefit limit. Therefore, coverage criteria has not been met.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 24 one-way transportation trips per calendar year when each one-way trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of additional mileage for routine transportation trips have not been met.Therefore, we decided that the Plan does not have to pre-approveadditional mileage for routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic ultrasound, massage, and electric stimulation.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a covered benefit.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 pre-approve chiropractic ultrasound, massage, and electric stimulation
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on May 2, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on May 2, 2019.