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

We decided that the Plan does not have to pay for nurse practitioner services provided on January 16, 2020.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says nonemergent,
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 nurse practitioner services provided on January 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide continued SNF care.
You asked the Plan to provide SNF care. You say that you are requesting review of denial of services. The Plan
denied your request. The Plan says you exhausted your 100 day SNF benefit.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that you received 100 days of SNF care during the benefit period from November 21, 2019
through June 24, 2020. The Plan has covered 100 days of SNF care.
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. You will be eligible for a new benefit period when you have not been
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the
Plan does not have to provide continued SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased January 29, 2020 from an out-ofnetwork
provider.
You asked the Plan to pay for the hearing aids. You say that you first used your hearing aid benefit in 2017 and
was not required to go through the Plan's provider. The 2017 benefits should apply because you were not made aware
that you had to go through the Plan's provider. The Plan denied your request. The Plan contract says for hearing aid
coverage you must see a Plan 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 purchased from a Plan vendor.
We looked at the file and the Plan's rules. 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 pay for
the hearing aids purchased January 29, 2020 from an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (CPT 81479) provided to the enrollee on April
15, 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 providers are required to code to specificity.
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 81479 is "unlisted molecular pathology procedure."
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 services. Our reviewer says that the
services at issue in this case were not coded correctly. Our physician reviewer found the enrollee has a history
of advanced stage lung cancer. The enrollee has had surgery and undergone treatment with chemotherapy. The
requested test is a next-generation molecular sequencing assay that tests a tumor's DNA and RNA to identify
somatic variants. The documentation does not discuss the requested test or how the test will guide treatment
recommendations for the enrollee.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for lab services (CPT 81479) provided to the enrollee on April 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on December 12, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the Plan should pay this claim.
The Plan denied your request. The Plan says there is no physician order.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis
provided on December 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on
January 20, 2020.
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 an assistant surgeon is almost never required for hydrocele repair.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to
establish medical necessity. In this case, you billed assistant surgery services for CPT code 55060. The
Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure.
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 services. Our reviewer says that it was
not medically reasonable or necessary to have an assistant surgeon in this case. Our physician reviewer found
an assistant surgeon is almost never required for hydrocele repair. The medical records indicate that this was a
routine hydrocelectomy that would not require an assistant.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for assistant surgeon services provided to the enrollee on January 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lens and frames purchased February 18, 2020 from an out
of network optical provider.
You asked the Plan to pay for the vision services. You say that you was never clearly notified that out of
network benefits were eliminated from the 2020 benefit plan. The Plan denied your request. The Plan says
services provided by an out of network provider is not covered.
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 out of network vision services is not covered.
We looked at the file and the Plan's rules. Services provided by an out of network provider is not covered.
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 the lens and frames purchased February 18,
2020 from an out of network optical provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on July 10, 2019.
You asked the Plan to pay for the hearing aids. You say that you chose the location is less than 1 mile away from home is located in Brooklyn and Long Island which is too far for you. The Plan denied your request. The Plan says hearing aids purchased from out of network providers are not covered.
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 hearing aids must be purchased The hearing benefit is not covered if the services are not ordered through the designated vendor. We looked at the file and the Plan's rules. 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 pay for hearing aids purchased on July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe nerve block injection provided on September 17, 2019.You asked the Plan to reduce the copayment forthe nerve block injection. You say that you have previously paid a $15 copayment for the nerve block injection. You say if you had been aware of the increased cost you would not have made the appointment. 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 a $300 copayment for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $300 copayment for the nerve block injection. The nerve block injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 reduce the copayment forthe nerve block injection provided on September 17, 2019.Our decision is only about the September 17, 2019 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services.
You asked the Plan to pay for the paramedic intercept services. You say that you were unaware two ambulances had responded to your medical emergency. You say that you feel as though the decision for a paramedic was made for you and you did not request the paramedic be called for your care. 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 pays for advanced life support (ALS) paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS) volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that the provider does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network
provider
You asked the Plan to pre-approve outpatient physical therapy. You say that the in-home physical therapy this
provider offers is important to you, and you cannot travel to other providers. The Plan denied your request. The
Plan says the denial of authorization for these services is correct, because this provider is out-of-network with
the Plan and you can be treated by an in-network provider.
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 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. 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 medical services to be provided by out of network provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided by the on July 12, 2019. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that the claim was originally processed with a $0 enrollee responsibility and you disagree with the reprocessing of charges. 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 20% coinsurance for Medicare Part B prescription drugs.  
 
The enrollee received a Medicare Part B drug injection on July 12, 2019. The allowed amount is $4,646.76 and 20% of that is $929.35.  
 
The enrollee has been asked to pay the total coinsurance amount of $929.35 for a Medicare Part B drug injection. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug injection provided on July 12, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysical therapy services to be provided with an out of network provider.You asked the Plan to pre-approvethe physical therapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The plan states there are equally qualified in-network providers available to the enrollee that can provide the care and treatment needed.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 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. 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-approvephysical therapy servicesto be provided with an out of network provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on June 24, 2019.
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 that the services are not covered as billed.
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. Specifically, Medicare rules say that health plans must submit a complete case
file to the IRE, including a copy of the enrollee's contract, appeal letter, and all documentation used to support
the health plan's denial. In this case, the Plan has not provided any documentation to support their denial in
regards to the process of submitting laboratory claims. There is no supporting
documentation provided by the Plan to show that Medicare criteria have not been met for payment of these
services. Therefore, we decided that the Plan has to pay for the laboratory services provided on June 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a CT scan and chemical agents used in
diagnostic procedures provided by an outpatient facility on April 5, 2019.
You asked the Plan to waive the coinsurance for a CT scan and chemical agents used in diagnostic procedures.
You say that the provider is supposed to cover the additional 20%. You say that you cannot afford this coinsurance.
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 outpatient diagnostic tests/outpatient diagnostic tests - radiological.
You have been asked to pay a 20% coinsurance of the allowed amount for a CT scan and chemical agents used
in diagnostic procedures. The total allowed amount is $8,382. The total amount you are being asked to pay is
$1,676.40 ($8,382 x 20% = $1,676.40). A CT scan and chemical agents used in diagnostic procedures falls
within the outpatient diagnostic tests/outpatient diagnostic tests - radiological 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 a CT scan and chemical agents used in diagnostic procedures
provided by a participating facility on April 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care from May 17, 2019 through June
14, 2019.
You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share
responsibility for the services you received. The Plan denied your request. The Plan says the claim was
processed accordingly with your 2019 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 SNF care from May 17, 2019 through June 14. You are asked to pay a $20 copayment per day for days 1-20 of a benefit period and $140 per
day for days 21-44. 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 SNF care from May 17, 2019
through June 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 12, 2019 by out
of network provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 12,
2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy and problem focused limited oral evaluation provided on August 27, 2019.
You asked the Plan to pay for the endodontic therapy and problem focused limited oral evaluation. You say that you called this provider's office before your appointment to confirm their participation in your Plan's network. You also say that the dental office did confirm that they were a provider. The Plan denied your request. The Plan says the services were rendered by a dentist who has formally 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 This provider. This provider 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 endodontic therapy and problem focused limited oral evaluation provided on August 27, 2019.
Your complaint about being misled by the provider's office is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.