Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses purchased from July 12, 2019 to November 1, 2019.
You asked the Plan to pay for the vision services. You say that you lost your eyeglasses while vacationing. You have never used the eye wear benefit and feel that you should be reimbursed $125. The Plan denied your request. The Plan says enrollee's must receive their vision care from an in-network provider. 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 vision services are provided by a participating vision care provider. We looked at the file and the Plan's rules. enrollee's must receive their vision care from an in-network provider 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 eyeglasses purchased from July 12, 2019 to November 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis cleaning (D1110) provided on December 17, 2019.
You asked the Plan to pay for the dental service. You say that you are appealing the denial to pay for your dental bill. It is a great hardship for you to take nearly $100 out of your budget of $150 per month. The Plan denied your request. The Plan says this request exceeds the benefit frequency limitation.
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. This service is allowed 2 times a year. Records show that this service was provided February 21, 2019 and May 29, 2019. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis cleaning (D1110) provided on December 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe X-ray (73590) provided on January 7, 2020.You asked the Plan to pay forthe X-ray. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available.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 forthe X-ray (73590) provided on January 7, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe ambulance transport provided on September 30, 2019.You asked the Plan to waive the coinsurance forthe ambulance transport. You say that this should be paid in full.The Plan denied your request. The Plan says that you have a 20% coinsurance for ambulance claims.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% coinsurance for ground ambulance services. You have been asked to pay a 20% coinsurance for the ambulance transport. The ambulance transport falls within the ground 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 coinsurance forthe ambulance transport provided on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on November 18, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized. The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on November 18, 2019.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment forthe comprehensive hearing test. We decided that the Plan does not have to waive the copayment forthe comprehensive hearing test. You asked the Plan to waive the copayment forthe comprehensive hearing test. You say that you have already paid the doctor for the same service. You say that you are appealing the facility charge.The Plan says that the $45 copayment applied correctly.We decided that the Planhas to reduce the copayment for the comprehensive hearing test. Your contract with the Plan clearly says that diagnostic hearing and balance evaluations performed by your provider to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider.The records show that only a comprehensive hearing test was billed. Therefore, we decided that the Plan has to reduce the copayment for the comprehensive hearing testfrom $45 to $20. We also decided that the Plandoes not have to waive the copayment forthe comprehensive hearing test.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 diagnostic hearing exam to treat disease and conditions of the ears.Therefore, we decided that the Plan does not have to waive the copayment forthe comprehensive hearing test.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) for tooth # 5 provided on January 9, 2019.
You asked the Plan to pay for the dental service. You say that you were advised by a plan representative that you could see this provider. The Plan denied your request. The Plan says the dental coverage through your previous dental plan ended on December 31, 2019. The Plan also says dental coverage is now available through Medicaid.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for 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 pay for the surgical extraction (D7210) for tooth # 5 provided on January 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stiolto Respimat Inhalation Spray.You asked the Plan to pre-approve Stiolto Respimat Inhalation Spray. You say that the enrollee has tried and failed a different drug. Plan denied your request. The Plan says the requested drug is not a Part B covered drug.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 pre-approve Stiolto Respimat Inhalation Spray.Benefits for Stiolto Respimat Inhalation Spray 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on December 17, 2019.You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 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 a domiciliary, rest home visit provided on December 17, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on October 1, 2019.
You asked the Plan to pay for the ambulance services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says payment for this ambulance transport is included in the SNF Part A stay as per Medicare guidelines.
The Plan must follow Medicare rules. The rules say that when Medicare pays for Part A SNF services patient transportation from a physician office falls under consolidated billing for the SNF. The services you have asked the Plan to pay for are ambulance transport services from a doctor's office while the enrollee was under inpatient status with a SNF. Therefore, we decided that the Plan does not have to pay for the transport from a physician's office provided on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the hyaluronan injection provided on December 30, 2019.
You asked the Plan to waive the coinsurance for the hyaluronan injection. You say that you paid your $40 copayment. You say that if the cost went up, insurance should cover it. The Plan denied your request. The Plan says the coinsurance applied correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for in-network chemotherapy and other drugs covered by Medicare Part B. You have been asked to pay $28.68, which is 20% of the allowed amount for the hyaluronan injection. The allowed amount is $143.40 (20% x $143.40 = $28.68). The hyaluronan 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 hyaluronan injection provided on December 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration.You asked the Plan to pre-approve bone marrow aspiration. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that this procedure is helpful.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 bone marrow aspiration. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental for spinal surgery. More research is needed to show the safety and efficacy of this procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met.Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 12, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the radiology services (72070, 72100 and Q0092). You say that you would like reconsideration because precertification/authorization should not be required for these services. The Plan denied your request. The Plan says utilization of network providers is required when possible and available.
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 medical services provided on December 12, 2019 by an out of network (OON) provider.
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-ofnetwork
provider on January 21, 2020.
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 January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on January 10, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges because this was an annual wellness visit. The Plan denied your request. The Plan says the claims were processed correctly, and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $25 copayment for primary care provider visits. The medical records show that the enrollee received services beyond an annual wellness visit on January 10, 2020. Therefore, the enrollee is responsible to pay the $25 copayment. The enrollee has been asked to pay a $25 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided on August 19, 2019 to September 24, 2019. You asked the Plan to waive the copayments for specialist visits. You say that due to the providers negligence you got an infection and feel that you should not be responsible for the follow-up visits. 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 each specialist visit. You received four specialist visits from August 19, 2010 to September 24, 2019. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the total allowed amount of $123.70, which is less than the total copayment amount. You have been asked to pay $123.70 for specialist visits. Specialist visits fall 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 copayments for specialist visits provided on August 19, 2019 to September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the ablation surgery provided from August 2, 2018 to August 3, 2018.
You asked the Plan to reduce the coinsurance for the ablation surgery. You say that you should be charged the inpatient copayment because you spent the night in the hospital. 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 per service for in-network outpatient surgical services at a hospital (includes professional fees). You have been asked to pay $3,781.34 which is 20% of the allowed amount for the ablation surgery. The allowed amount is $18,906.69. ($18,90.69 x 20% = $3,781.34). The ablation surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were considered an outpatient.
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 reduce the coinsurance for the ablation surgery provided from August 2, 2018 to August 3, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on February 11, 2020.
You asked the Plan to pay for the dental service. You say that you needed the x-rays to see if there was a problem with your tooth roots. The Plan denied your request. The Plan says bitewing x-rays are not a covered service.
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, bitewing x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on February 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forShoulder elbow wrist hand orthosis (SEWHO) (L3960).You asked the Plan to pay forthe orthosis. You say that please see the attached medical records which prove the medical necessity of the item and process the claim for payment.The Plan denied your request. The Plansays the medical record does not adequately support the medical necessity for the item.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 pay for the orthosis. Our reviewer says that this item is not medically necessary for the enrollee. Our physician reviewerfound the documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. The documentation does not support that the shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case, as there is no documentation of a medical condition involving the enrollee's shoulder joint. 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 orthosis have not been met.Therefore, we decided that the Plan does not have to pay forShoulder elbow wrist hand orthosis (SEWHO) (L3960).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on November 13, 2019.
You asked the Plan to waive the coinsurance for an injection. You say that you are on social security. You say that you cannot afford this coinsurance on top of the physician copayment you had to pay. The Plan denied your request. The Plan says the correct coinsurance has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $810. The total amount you are being asked to pay is $162 ($810 x 20% = $162). The correct coinsurance has been applied to the injection that was provided. An 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 an injection provided by a participating provider on November 13, 2019.