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

We decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network provider.
You asked the Plan to pre-approve the office visits. You say that you do not have faith in anyone other than this provider. The Plan denied your request. The Plan says there are in-network providers that are available to provide the 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. 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 the office visits to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for remote cardiac rhythm monitor evaluation provided on January 6, 2021.

You asked the Plan to waive the copayment for diagnostic procedure. You say that this appointment was cancelled. 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 $40 copayment for diagnostic procedures and tests. The record shows that this remote device evaluation was provided on this date of service, therefore the diagnostic procedures copayment applies to this claim. 

You have been asked to pay $40 copayment for diagnostic procedure. Diagnostic procedure falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for remote cardiac rhythm monitor evaluation provided on January 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve full body vibration plate machine (CPT code A9300).

You asked the Plan to pre-approve the machine. You say that you are a double amputee resulting in you being disabled and cannot exercise how you used to. You state this equipment is for you to exercise your whole body. The Plan denied your request. The Plan says the machine is not covered because it is not medical in nature and is regularly and primarily used by persons who do not have a specific medical need for them.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve full body vibration plate machine (CPT code A9300).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on July 13, 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 due to the enrollee's hospice status at the time of service, this claim should be submitted
to Original Medicare.

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 for physician services provided to the enrollee on July 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 11, 2021 by an out of network (OON) provider.
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 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 laboratory services provided on January 11, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on October 23, 2020.

You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says coverage for hearing aids is limited to the Plan's hearing aid provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's hearing aid provider. 

We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on October 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 14, 2021.

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 are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for MRI, spinal canal and contents, cervical; without contrast material (CPT code 72141) provided on December 18, 2020.
You asked the Plan to waive the copayment for the MRI. You say that the copayment is expensive for an MRI. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 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 spinal canal MRI on December 18, 2020. The Medicare-allowed amount for the EKG is less than the set $250 copayment; therefore, you have been asked to pay the lesser amount of $206.16 for the MRI. Your 2020 EOC states, "enrollees must pay a $250 copayment per day for Medicare-covered diagnostic radiology services ($100 ultrasound). Diagnostic radiology services, such as ultrasound, nuclear cardiac imaging, PET, MRI, and CT scan." 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 MRI, spinal canal and contents, cervical; without contrast material (CPT code 72141) provided on December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99308) provided on November 17,
2020.
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The
Plan denied your request. The Plan says 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 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 nursing facility care (99308) provided on November 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a weather cover and cup holder for a power wheelchair.
You asked the Plan to pre-approve weather cover and cup holder. You say that the enrollee needs this. The Plan denied your request. The Plan says the denial of authorization for this component is correct, because this is not primarily medical in nature and is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a weather cover and cup holder for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the face-down recovery system rental
(E1399) provided on October 27, 2020.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit under your
contractual policy or by Medicare.
The Plan must follow Medicare rules. Medicare rules say that these devices are statutorily non-covered because
they do not fall within a Medicare benefit category. These types of devices are considered "precautionary
devices" and also can be used for purposes other than the treatment of an illness or injury.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of this item have not been met. Specifically, these devices are statutorily non-covered because they do
not fall with a Medicare benefit category and can be used for purposes other than treatment of an illness or
injury. Therefore, we decided that the Plan does not have to issue reimbursement for the face-down recovery
system rental (E1399) provided on October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you are a fall risk. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services described by dental codes D6057, D6058, and D6010.

You asked the Plan to pre-approve dental codes D6057, D6058, and D6010. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental codes D6057, D6058, and D6010 are not covered under the Plan's supplemental dental benefit.

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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services described by dental codes D6057, D6058, and D6010.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the TDAP vaccine (90715) provided on March 4, 2021.

You asked the Plan to pay for the TDAP vaccine. You say that you would like reconsideration because you are ill and require vaccines. The Plan denied your request. The Plan says this immunization is not covered by your Medicare Part B Plan.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP vaccine. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the TDAP vaccine. Therefore, we decided that the Plan does not have to pay for the TDAP vaccine (90715) provided on March 4, 2021.

Benefits for the TDAP vaccine 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit and the cardiac rehab visits provided from September 3, 2020 to October 28, 2020.
You asked the Plan to waive the copayments for the specialist office visit and the cardiac rehab visits. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a specialist office visit on September 3, 2020 and cardiac rehab visits from September 4, 2020 to October 28, 2020. The Plan says that 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 $50 copayment for specialist office visits and a $25 copayment per cardiac rehab visit. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a specialist office visit on September 3, 2020. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the Physician/Practitioner services benefit category. The file shows that you received cardiac rehab visits from September 4, 2020 to October 28, 2020. You have been asked to pay a $25 copayment for each cardiac rehab visit. The cardiac rehab visits fall within the Cardiac 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 pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the specialist office visit and the cardiac rehab visits provided from September 3, 2020 to October 28, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit services described by current procedural terminology (CPT) code 99214 provided on February 10, 2021.
You asked the Plan to pay for CPT code 99214. 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers should submit telehealth services claims, using Place of Service (POS) 02 - Telehealth, to indicate they furnished the billed service as a professional telehealth service from a distant site.
We looked at the file and Medicare rules. The services at issue were telehealth services that were not billed with POS 02. Based on this information, we decided that Medicare rules for coverage of CPT code 99214 have not been met. Therefore, we decided that the Plan does not have to pay for the office visit services described by current procedural terminology (CPT) code 99214 provided on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections provided from November 2, 2020 to January 8, 2021.
You asked the Plan to waive the coinsurance for the Part B injections. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received Part B injections on the dates of service at issue in this appeal. The Plan says that the correct coinsurance has 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 20%
coinsurance for Medicare Part B prescription drugs. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received Part B injections on November 2, 2020, December 7, 2020 and January 8, 2021. You have been asked to pay a 20% coinsurance for each Part B injection. The Part B injections fall within the Medicare Part B prescription drugs 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 pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Part B injections provided from November 2, 2020 to January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology procedure level 2 (CPT code 81401) and molecular pathology procedure level 7 (CPT code 81406) provided to the enrollee on October 29, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Medicare guidelines say that tier 2 genetic tests like the POLG test you had performed are "are unlikely to impact therapeutic decision-making, directly impact treatment, outcome and/or clinical management in the care of the beneficiary and will be denied as not medically necessary." These testing panels/codes for mitochondrial genes are non-covered items. Under Medicare guidelines, your request is not a covered benefit. Therefore, we decided that the Plan does not have to pay for molecular pathology procedure level 2 (CPT code 81401) and molecular pathology procedure level 7 (CPT code 81406) provided to the enrollee on October 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) provided March 10,
2021.
You asked the Plan to pay for the oral hygiene instructions. You say that the dental exam should be covered.
The Plan denied your request. The Plan says the dental exam and cleaning were covered but the oral hygiene
instructions as billed by the provider are not a covered service under your benefits.
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
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral
hygiene instructions (D1330) provided March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth service (99202) provided
February 12, 2021.
You asked the Plan to waive the copayment for the telehealth service. You say that the service was just a
phonecall and the copayment should be waived. The Plan denied your request. The Plan says the correct
copayment was 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 $10
copayment for Office visits.
You have been asked to pay a $10 copayment for the telehealth service. The telehealth service falls within the
Office visits benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a telehealth service (99202) provided February 12, 2021.