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

We decided that the Plan does not have to pay forthe services provided to you on November 21, 2019.You asked the Plan to pay forthe services. You say that you shouldn't be liable.The Plan denied your request. The Plan says the claim needs to be submitted to the primary insurer.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified  as the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay forthe services provided to you on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture and a mandibular partial
denture.
You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that
you lost your dentures. The Plan denied your request. The Plan says these services are allowed one time every
60 months. The Plan also says that you had these services 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, if there is a pre-existing prosthesis, it
must be at least 5 years old and unserviceable to qualify for replacement. The contract also says that
replacement of lost or broken dentures less than 5 years of age is not a covered benefit. The record shows that
you received maxillary and mandibular partial dentures on October 8, 2016 and your dentures benefit has been
exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture and
a mandibular partial denture.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you on January 3, 2019, and September 30, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider that has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the services provided to you on January 3, 2019, and September 30, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for folic acid assay testing provided on November 12, 2019.
You asked the Plan to pay for laboratory test. You say that this testing is allowed 4 times per year. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test should not be performed more than once per year.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. 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 specify whether the ordering physician is in-network or out-of-network with the Plan. The documentation submitted does not include prior notice that this testing would not be covered by the Plan. Without this information, we cannot determine whether the lab order made by the physician constitutes plan-directed care, which would justify coverage of this claim. Therefore, the Plan has not shown that its decision to deny payment for this claim is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for folic acid assay testing provided on November 12, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora follow-up office visit provided by Dr.on September 26, 2019.You asked the Plan to waive the copayment fora follow-up office visit. You say that this was a follow-up appointment. You say that you should not have a copayment for this.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). The enrollee's contract with the Plan clearly says that enrollees must pay a $45 copayment for physician/practitioner services/specialist office visit. The enrollee has been asked to pay a $45 copayment for a follow-up office visit. Follow-up office visits are still subject to a copayment amount; therefore, the correct copayment has been applied. A follow-up office visit falls within the physician/practitioner services/specialist office visit 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 fora follow-up office visit provided by Dr. on September 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from December 3, 2019 through December 5, 2019.You asked the Plan to waive the copayment for the inpatient stay. You say that you were in the hospital less than 24 hours and no procedure was performed. You say that the charges should be corrected.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments,deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment per day for days 1-5 at an in-network inpatient hospital.You have been asked to pay a $590 copayment for the inpatient stay. ($295/day x 2 days = $590). The inpatient stay falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from December 3, 2019 through December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2020) and progressive lenses (V2781) purchased on October 30, 2019.
You asked the Plan to pay for the vision services. You say that you used a plan optometrist and a plan approved eyeglass provider. You paid out of pocket because the provider would not file a claim for the lesser expensive glasses and you request reimbursement. The Plan denied your request. The Plan says this claim has been processed correctly.
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 rendered by a non-optical provider. The health plan contract on page 88 says any benefits received at a non-network optical provider is not covered. We looked at the file and the Plan's rules. For covered services you must see a network optical 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 deluxe frames (V2020) and progressive lenses (V2781) purchased on October 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental treatment/reconstruction with new crowns.You asked the Plan to pre-approvedental treatment/reconstruction with new crowns. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not a covered 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.Review of the file shows that the requested dental services are identified with codesD4341, D0999, D2740, D2954, D3330, D6057, D6061. These codes are not listed as covered dental codes. 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-approvedental treatment/reconstruction with new crowns.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on January 14, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for podiatry services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network.
The Plan says that no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 podiatry services provided on January 14, 2020 by
an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite - two surfaces, anterior (D2331) provided on January 7, 2020 by an in-network provider. You asked the Plan to pay for the dental services. You say that you are requesting additional payment for dental services you received. The Plan denied your request. The Plan says the claim was processed accordingly
with your 2019 EOC 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. The allowed amount for the service was $122.00, the Plan paid 50% which leaves you responsible for $61.00. Therefore, we decided that the Plan does not have to pay for resin-based composite - two surfaces, anterior (D2331) provided on January 7, 2020 by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Pride Go Chair G2 electric wheelchair.You asked the Plan to pre-approvea Pride Go Chair G2 electric wheelchair. You say that you need this wheelchair to better fit inside your home.The Plan denied your request. The Plan says another electric wheelchair is not medically necessary.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have a HD Jazzy Select Elite electric wheelchair. a HD Jazzy Select Elite electric wheelchair serves the same purpose as a Pride Go Chair G2 electric wheelchair.Therefore, we decided that the Plan does not have to pre-approvea Pride Go Chair G2 electric wheelchair
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a scooter lift for a vehicle.
You asked the Plan to pre-approve the lift. 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 state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. It is for use with a vehicle. Therefore, we decided that the Plan does not have to pre-approve a scooter lift for a vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies.
You asked the Plan to pre-approve a continuous glucose monitor and supplies. You say that you need a CGM
to help lower your A1c and keep your sugars lower. The Plan denied your request. The Plan says based on the
information made available the medical necessity for this equipment has not met Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they
are medically reasonable and necessary and replace a blood glucose monitor.
We looked at the file and Medicare rules. The medical records show you test twice a day and do not make
frequent adjustments to your insulin regimen. Based on this information, we decided that Medicare rules for
coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve a continuous glucose monitor and supplies.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from October 3, 2019 to October 28, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment is not allowed for this service because it was billed with an incorrect type of bill code.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim has been submitted with an invalid type of bill code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 3, 2019 to October 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided in a specialist's office on November 11, 2019.You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the charges because you never saw the provider.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 for X-ray's provided in a specialist's office. The medical records show that you received an X-ray on November 11, 2019. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for an X-ray. An X-ray 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 an X-ray provided in a specialist's office on November 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea maxillary partial denture (D5225) and a mandibular partial denture (D5226).You asked the Plan to pre-approvethe maxillary and mandibular partial dentures. You say that your current partials are broken. You also say that this is medically necessary.The Plan denied your request. The Plan says these services exceed the maximum count allowed per period.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, maxillary partial denture (D5225) and mandibular partial denture (D5226) are each limited to one procedure every five plan years. The record shows that you received maxillary and mandibular partial dentures on August 24, 2018 and your dentures benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approvea maxillary partial denture (D5225) and a mandibular partial denture (D5226).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion services provided by provider and Infusion from December 25, 2019 to December 31, 2019.You asked the Plan to pay forhome infusion services. You say that on the Centers for Medicare and Medicaid Services (CMS) website, this is listed as a valid code.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this procedure code is not valid for Medicare purposes and is not payable.The Plan must follow Medicare rules. Medicare rules say that procedure code S9328 is not valid for Medicare purposes and is not payable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home infusion services have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion services provided by provider and Infusion from December 25, 2019 to December 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided to the enrollee from August 9, 2019, to October 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was admitted before enrolling in her current plan.
The Plan must follow Medicare rules. Medicare rules say that if coverage under an MA plan offered by an MA organization begins while the beneficiary is an inpatient, payment for inpatient services until the date of the beneficiary's discharge is made by the previous MA organization or original Medicare. We looked at the file and Medicare rules. The enrollee in this case was admitted as an inpatient on May 15, 2019. The enrollee was enrolled in the Plan on August 1, 2019 during the inpatient stay. The Plan is not responsible for payment for inpatient services when the enrollee was admitted prior to enrollment with the Plan. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient services provided to the enrollee from August 9, 2019, to October 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 10, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for laboratory tests. You say that you are appealing. The Plan denied your request.
The Plan says the denial of payment for these services is correct, because this provider is out-of-network with
the Plan and the ordering physician is also out-of-network with the Plan.
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 October 10, 2019
by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on November 23, 2019.You asked the Plan to waive the copayment for an ER visit. You say that the ER told you that you need to see a specialist and could not help you.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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for an ER visit. An ER visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for an ER visit provided on November 23, 2019.