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

We decided that the Plan does not have to waive the copayment for emergency care provided on September 28, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the copayment because the services were medically necessary. 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 $110 copayment for emergency care. You have been asked to pay a $110 copayment for emergency care. Emergency care 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 emergency care provided on September 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prostate cancer screening rendered on August 31, 2020.You asked the Plan to pay forthese services. You say that the screening was needed to identify a problem with your PSA levels.The Plan denied your request. The Plan says the services exceed the benefit limit.The Plan must follow Medicare rules. The rules say that each prostate screening test may be paid at a frequency of once every 12 months for men who have attained age 50.We looked at the file and Medicare rules. The file shows that you had a prostate screening on August 31, 2020. You previously received these services on February 27, 2020 for which the Plan approved and paid. The screening on August 31, 2020 was performed less than 12 months from your previously covered exam. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe prostate cancer screening rendered on August 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on May 25, 2020.
You asked the Plan to pay for the ambulance services. You say that your husband was the person that fell and was injured. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 25, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient office visit (99214) provided August 26, 2020.You asked the Plan to waive the copayment forthe office visit. You say that you were told that there would be no copay by your PCP.The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.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 $10 copayment covered visit or consultation in an outpatient location with your PCP or other primary care provider. You have been asked to pay $10 copayment for the office visit. The office visit falls 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 copayment forthe outpatient office visit (99214) provided August 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided to the enrollee on March 6, 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 claim was received past the allowed 12 month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until September 24, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for radiology services provided to the enrollee on March 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided.

You asked the Plan to pay for the physician's services. 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 Plandid not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the knee orthosis and sleeve provided to the enrollee on July 23, 2020.
You asked the Plan to pay for these items. You say that these items were medically necessary. The Plan denied your request. The Plan says that that the billed supply code cannot be verified.
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 contains a valid proof of delivery for the supplies provided in this case. The packing slip includes a invoice number and tracking number that corroborates the proof of delivery sent to the Plan. Therefore, we decided that the Plan has to pay for the knee orthosis and sleeve provided to the enrollee on July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, prophylaxis, preventive procedure, and two drugs or medicaments dispensed in the office for home use provided on July 2, 2020, and July 17, 2020 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, prophylaxis, preventive procedure, and drugs or medicaments. You say that there are no in-network dentists near you. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that you did not contact the Plan prior to the services being rendered to verify benefits and provider eligibility.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, prophylaxis, preventive procedure, and two drugs or medicaments dispensed in the office for home use provided on July 2, 2020, and July 17, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 27, 2019.
You asked the Plan to pay for the ambulance services. You say that this is a financial hardship. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 27, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a gradient compression stocking provided on June 25, 2020.You asked the Plan to pay for the gradient compression stocking. The Plan denied your request. The Plan says the gradient compression stocking must be purchased from a contracting supplier.Medicare rules say that plans can require enrollees toget 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 gradient compression stocking. We found no exception that would require the Planto pay for this item. Therefore, we decided that the Plan does not have to pay for a gradient compression stocking provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for hospital care (99233) provided on July 19, 2020.
You asked the Plan to pay for hospital care. You say that this should be covered. The Plan denied your request. The Plan says that this was billed with a missing or inappropriate modifier.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided information to show what modifier is required on this service. The submitted records do no clearly demonstrate why the billing of this code is invalid without a modifier. Therefore, we decided that the Plan has to pay for hospital care (99233) provided on July 19, 2020.
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 pay for laboratory services provided on July 8, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.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 laboratory services. 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 laboratory services provided on July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 8, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that in most cases, care members receive from an out-of-network provider will not be covered. If the member needs medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, the member can get this care from an out-of-network provider. Authorization should be obtained from the plan prior to seeking care. Providers are responsible to check eligibility prior to seeing members and for confirming member's coverage for the date of service.
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 physician's services provided on February 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued on September 14, 2020.
You asked the Plan to pay for the compression stockings. You say that this should be covered because your doctor said you needed the compression stocking. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued on September 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulate (manual) therapy provided on July 21, 2020.
You asked the Plan to pay for the electrical stimulate (manual) therapy. The Plan denied your request. The Plan says prior authorization is required for out-of-network services that are 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 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 electrical stimulate (manual) therapy provided on July 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Sitz bath chair.
You asked the Plan to pre-approve a Sitz bath chair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 bath/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 Sitz bath chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits provided from January 8, 2020, to August 20, 2020.
You asked the Plan to pay for office visits. You say that you are requesting payment for these services. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is not enrolled in Medicare and is not payable.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered items or services, a provider must be enrolled in the Medicare program. We looked at the file and Medicare rules. This provider is not enrolled in the Medicare program and is not eligible for payment. Based on this information, we decided that Medicare rules for coverage of office visits have not been met. Therefore, we decided that the Plan does not have to pay for office visits provided from January 8, 2020, to August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite - four or more surfaces, posterior (D2394) tooth 3 MOBL provided October 19, 2020.
You asked the Plan to pay for the dental services. You say that you would like to appeal because you spoke to a representative and was told you had full coverage. The Plan denied your request. The Plan says this service is not covered under the plan 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 resin-based composite - four or more surfaces, posterior (D2394) tooth 3 MOBL provided October 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 27, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 21015 and 42415 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 21015 is radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; less than 2 cm. The definition of code 42415 is excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of facial nerve. We find that CPT codes 21015 and 42415 are not supported in the medical record. Specifically, there is no documentation of a radical tumor resection to support code 21015. There is no documentation of an excision of a parotid tumor or parotid gland to support code 42415. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on January 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the mammogram and the ultrasound provided on February 7, 2020.
You asked the Plan to waive the deductible for the mammogram and the ultrasound. You say that these services were preventive and should not apply to the deductible. 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. Your contract with the Plan says that there is a $250 deductible that applies towards outpatient hospital services. The ultrasound you asked the Plan to waive the deductible for falls within the "Outpatient hospital services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible that applies towards outpatient hospital services. The record shows you were not charged for the mammogram. The record shows that the ultrasound is not considered a preventive service and therefore applied to the deductible.
This cost sharing is a contractual obligation that had not been met at the time the mammogram and the ultrasound was received on February 7, 2020. Therefore, we decided that the Plan does not have to waive the deductible for a mammogram and an ultrasound provided on February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist visits provided on August 21, 2020 and August 27, 2020.
You asked the Plan to waive the copayments for the specialist 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 services provided by a specialist on the dates of service at issue in this appeal. 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 $35 copayment for each visit to a specialty physician office. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received specialty services on August 21, 2020 and August 27, 2020. You have been asked to pay a $35 copayment for each specialist visit. The specialist visits fall within the Physicians/Practitioners 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 visits provided on August 21, 2020 and August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tracheal suction catheters identified with code A4624 provided on June 1, 2020.
You asked the Plan to pay for the tracheal suction catheters. 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 payable as billed.
The Plan must follow Medicare rules. Medicare rules say that tracheal suction catheters are only covered when billed with certain diagnosis codes. We looked at the file and Medicare rules. Review of the file shows that these items were billed with diagnosis code N31.2 (Flaccid neuropathic bladder, not elsewhere classified). Diagnosis code N31.2 is not listed as a diagnosis code that supports medical necessity for these items provided. Based on this information, we decided that Medicare rules for coverage of the tracheal suction catheters have not been met. Therefore, we decided that the Plan does not have to pay for the tracheal suction catheters identified with code A4624 provided on June 1, 2020.