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

We decided that the Plan does not have to pay for the injections provided on September 3, 2019 by the out of network provider.
You asked the Plan to pay for the surgical services. You say that the services were provided to the enrollee in good faith. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says the services were not urgent or emergent in nature.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The facility is not a network provider either. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the injections provided on September 3, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided on July 16, 2019.You asked the Plan to waive the copayment for vision services. 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 $40 copayment for exams to diagnose and treat diseases of the eye.The medical records show that you received vision services to diagnose and treat diseases of the eye. Therefore, you are responsible to pay the $40 copayment.  You have been asked to pay a $40 copayment for vision services. Vision services fall within the vision 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 forvision services provided July 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided April 29, 2019 to June 23, 2019.
You asked the Plan to pay for the self-administered drugs. You say that the drugs were not administered by the member. The Plan denied your request. The Plan says even if the drugs were not administered by the member, they were of the type that is typically self-administered, and therefore cannot be covered under the Part B Medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided April 29, 2019 to June 23, 2019.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided.
You asked the Plan to pay for the physician services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the physician services provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent
nor urgent and prior authorization was not obtained to provide 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99251 provided.
You asked the Plan to pay for CPT code 99251. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, CPT code 99251 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for CPT code 99251 provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code G0482 provided on July 9, 2019.You asked the Plan to pay forCPT code G0482. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the medical records do not support the billing of CPT code G0482.The Plan must follow Medicare rules. Medicare rules say that providers must reportservices correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code G0482 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed.We find that CPT code G0482 is not supported in the medical record. Specifically, the record does not contain evidence that definitive testing on 15-21 drug classes was performed. Based on this information, we decided that Medicare rules for coverage of CPT code G0482 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code G0482 provided on July 9, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe outpatienttherapy services provided from June 28, 2019 to August 6, 2019.You asked the Plan to waive the copayments forthe outpatient therapy services. You say that you feel you should not be responsible for these cost share amounts and you would like the plan to reconsider your request.The Plan denied your request. The Plan says you received outpatient therapy on the dates of service at issue in this appeal. The plan states the correct copayments have applied per your contract with the plan.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 $40 copayment for Outpatient rehabilitation services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient therapy from June 28, 2019 to August 6, 2019. You have been asked to pay a $40 copayment for each date of service, totaling $440. The outpatient therapy services fall within the Outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amounts based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to paywhen you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forthe outpatient therapy services provided from June 28, 2019 to August 6, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on July 10, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, 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. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place.Therefore, we decided that the Plandoes not have to pay forthe laboratory services provided on July 10, 2019
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided.
You asked the Plan to pay for the chiropractic services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care. The plan states there are equally qualified in-network chiropractors available to you that could have provided the services you received.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on May 30, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the services were not urgent or emergent.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The rendering provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee on May 30, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency ambulance transport (A0428) and ground mileage (A0425) provided on April 15, 2018. You asked the Plan to pay for non-emergency ambulance transport and ground mileage. You say that the enrollee was not enrolled in hospice at the time of service.The Plan denied your request. The Plan says based on Medicare billing criteria, Medicare fee-for-service retains payment responsibility for all hospice and non-hospice related claims beginning on the date of the hospice election.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay fornon-emergency ambulance transport (A0428) and ground mileage(A0425) provided on April 15, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frame (V2025) and progressive lens, per lens (V2781) purchased on July 31, 2019.
You asked the Plan to pay for the eyewear. You say that you had cataract surgery on April 29, 2019 which required you to get different lenses. The Plan denied your request. The Plan says the service is not covered under your contract under any normal circumstance. The Plan states your benefits for glasses after cataract surgery, deluxe frames and progressive lenses are excluded.
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. Deluxe frames and progressive lenses are excluded. Therefore, we decided that the Plan does not have to pay for deluxe frame (V2025) and progressive lens, per lens (V2781) purchased on July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on May 17, 2019 by out of network provider. You asked the Plan to pay for these out-of-network services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on May 17, 2019 by out of network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary/rest home visit (99335) provided on
July 18, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the plan's denial as the patient was not enrolled in hospice. The Plan denied your request. The Plan says original Medicare is responsible for payment of these services.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the domiciliary/rest home visit (99335) provided on July 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided to the enrollee on June 5, 2019. You asked the Plan to pay for out of network providers. 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the physician services provided to the enrollee on June 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided from February 18, 2019 to February 20, 2019.
You asked the Plan to pay for the critical care services. You say that the records support the billed services. The Plan denied your request. The Plan says since no time spent is documented in the progress notes, payment for critical care services may not be made.
The Plan must follow Medicare rules. Medicare rules say that critical care progress notes must document the amount of time spent providing care. In this case, the progress notes for these services do not have any time documented. Therefore, we decided that the Plan does not have to pay for the critical care services provided from February 18, 2019 to February 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 10, 2019 to October 29, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says valid proof of delivery was not submitted.
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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 10, 2019 to October 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110), and the partial maxillary denture (D5211) provided on July 9, 2019.You asked the Plan to pay for the dental services. You say that you were assured by the dentist and staff that your insurance would cover the services. You also say that you called to inquire and they explained the wrong code was entered in your info.The Plan denied your request. The Plan says as of July 9, 2019 you had $529 of your dental allowance remaining. The Plan says that the $529 was applied to the services that you received on July 9, 2019.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 and dentures are a covered service, the annual maximum of $2,250 was reached during the processing of the claim. The record shows that you used $1,721 worth of your annual maximum on April 25, 2019, June 4, 2019, and June 17, 2019.Therefore, we decided that the Plan does not have to pay for the complete maxillary denture (D5110), and the partial maxillary denture (D5211) provided by on July 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2740) for tooth # 31 provided on July 31, 2019.You asked the Plan to pay for the dental service. You say that you needed 2 crowns at the same time. You say that both teeth had large fillings. You say that the fillings were broken and there was recurrent decay underneath. You also say you needed both crowns done before your partial could be completed.The Plan denied your request. The Plan says the frequency limit of one crown per calendar year has been exceeded.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 and crowns are a covered service, the frequency limit has been exceeded. The record shows that the crown for tooth # 28 that was also received on July 31, 2019 was paid.Therefore, we decided that the Plan does not have to pay forthe porcelain crown (D2740) for tooth # 31 provided on July 31, 2019.