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

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on December 10, 
2019. 
 
You asked the Plan to waive the copayment for an eye exam. You say that you disagree with the charges 
because this was a routine eye exam. 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 exams to diagnose and treat diseases of the eye for vision care.  
 
The record shows that you received an eye exam on December 10, 2019 that went beyond routine services. 
Therefore, you are responsible to pay the $35 copayment.  
 
You have been asked to pay a $35 copayment for an eye exam. An eye exam falls within the vision 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 eye exam provided on December 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive 
the coinsurance for a Medicare Part B drug injection provided on June 9, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit and to waive the coinsurance for a Medicare 
Part B drug injection. You say that you feel that the charges are too high and were not charged this much in the 
past. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for specialist services. Your contract with the Plan also clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You had a specialist visit on June 9, 2020. Therefore, you are responsible to pay the $40 copayment.  
 
 
 
You received a Medicare Part B drug on June 9, 2020. The allowed amount is $852.50 and 20% of that is 
$170.50.  
 
The total amount you owe is: $210.50. 
 
You have been asked to pay the total amount of $210.50 for a specialist visit and a Medicare Part B drug 
injection. A specialist visit falls within the physician/practitioner services, including doctor's office visits 
benefit category. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive the 
coinsurance for a Medicare Part B drug injection provided on June 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 27, 2020.

You asked the Plan to waive the copayment for a specialist visit. You say that you were told that you would not owe a copayment for the follow-up visit. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialist visits.

You had a follow-up visit with a specialist on July 27, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the allowed amount of $35.80, which is less than the $40 copayment. 

You have been asked to pay $35.80 for a specialist visit. A specialist 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 for a specialist visit provided on July 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 15, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that prior authorization was not obtained due to referring 
provider doing random screenings for drugs. The Plan denied your request. The Plan says prior authorization 
was not obtained. The Plan says that the referring provider is also out-of-network. 
 
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 lab work provided on January 15, 2020 by an out 
of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trigger point injections provided on May 27, 2020. 
 
You asked the Plan to pay for Injection(s); single or multiple trigger point(s), 3 or more muscles (20553). You 
say that the Plan should pay this claim. The Plan denied your request. The Plan says modifier 50 is unwarranted 
on this claim. 
 
The Plan must follow Medicare rules. The rules state that modifier 50 is used to report bilateral procedures. 
 
A modifier provides the means to report or indicate that a procedure that has been performed has been altered 
by some specific circumstance but not changed in its definition or code. The code does not contain any 
terminology that warrants the use of a bilateral modifier. Based on this information, we decided that Medicare 
rules for coverage of services billed with a -50 modifier have not been met. Therefore, we decided that the Plan 
does not have to pay for the trigger point injections provided on May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the comprehensive oral evaluation provided on July 23, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that the services provided were 
necessary and should be covered. The Plan denied your request. The Plan says that the comprehensive oral 
evaluation is limited to once every three years and since the enrollee last had a comprehensive oral evaluation 
in 2018 the Plan will not cover it for 2020. 
 
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 Plan covers  the 
comprehensive oral evaluation when the services are received once every three years. 
 
We looked at the file and Medicare rules. The records provided indicate that you last received a comprehensive 
oral evaluation in 2018. However, the Plan?s 2018 EOC indicates that at that time they were offering to cover 
two procedures per year for comprehensive oral evaluation. This indicates that when you last received a 
comprehensive oral evaluation, the contract rules for coverage were different than they are now in 2020. Using 
past claims that were under a different set of contractual rules would not be appropriate for this situation. The 
2020 benefits for a comprehensive oral evaluation have not been exhausted. Based on this information, we 
decided that the Plan's rules for coverage of the comprehensive oral evaluation have been met. Therefore, we 
decided that the Plan has to pay for the comprehensive oral evaluation provided on July 23, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by Victor Farmington 
Volunteer Ambulance Corps, Inc. on November 29, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place. 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 November 29, 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 by Victor 
Farmington Volunteer Ambulance Corps, Inc. on November 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Magnetic Resonance Imaging (MRI) of the spine (72148) 
provided June 18, 2020. 
 
You asked the Plan to pay for the MRI of the spine. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this claim is a duplicate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 72148 is not supported in the medical record. Specifically, the record shows a claim for 
this procedure was already paid for the same service date. The provided medical records do not support a 
second instance of this procedure being performed. Based on this information, we decided that Medicare rules 
for coverage of the MRI of the spine have not been met. Therefore, we decided that the Plan does not have to 
pay for Magnetic Resonance Imaging (MRI) of the spine (72148) provided June 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation failed to prove that sufficient evidence 
of four-week trial of conservative therapy. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has undergone a four week trial of conservative therapy including 
exercise, elevation, and compression garments. Therefore, we decided that the Plan does not have to pay for 
intermittent limb compression device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for four additional foot inserts provided to the enrollee on May 
11, 2020. 
 
You asked the Plan to pay for four additional foot inserts. You say that you would like payment made for these 
items. The Plan denied your request. The Plan says that only one unit per foot is allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code L3031 is two. You billed six units of this code, exceeding the MUE. Based 
on this information, we decided that Medicare rules for coverage of four additional foot inserts have not been 
met. Therefore, we decided that the Plan does not have to pay for four additional foot inserts provided to the 
enrollee on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the bevacizumab provided by intravitreal injection on 
February 14, 2020. 
 
You asked the Plan to pay for the bevacizumab. You say that these injections and the drugs used should be 
covered. The Plan denied your request. The Plan says this drug was not billed with the proper code for 
ophthalmic use. 
 
The Plan must follow Medicare rules. Medicare rules say that when billing for bevacizumab for use in 
intravitreal injections, providers must use code J7999. 
 
This claim was not billed using the correct code based on the MAC billing rules.  
 
Therefore, we decided that the Plan does not have to pay for the bevacizumab provided by intravitreal injection 
on February 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided on June 12, 2020. 
 
You asked the Plan to waive the copayment for wound care. You say that you feel the charges are too high for 
the service. 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 $200 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You have been asked to pay a $200 copayment for wound care. Wound care 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 waive the copayment for wound care provided on June 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee out of network 
on July 20, 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 the enrollee did not have prior authorization for 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 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 
to the enrollee out of network on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 23, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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. 
 
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 
physicians 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 on July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for eye exam (92004) and retinal imaging (92227) provided on July 25, 2020 by an out-of-network provider.

You asked the Plan to pay for vision services. You say that the services rendered were medically necessary. The Plan denied your request. The Plan says that the services provided are not a Medicare covered benefit.

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, the Plan has not provided their 2020 Evidence of Coverage for review. The Evidence of Coverage is considered to be within the Plan's control. Without the Evidence of Coverage, the denial is not substantiated, and we must find in your favor.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you received on May 12, 2020. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
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 provided during a routine exam. 
 
We looked at the file and the Plan's rules. The requested eye refraction was not performed during a routine eye 
exam. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the eye refraction you received on May 
12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120), prophylaxis (D1110), bitewing 
x-rays (D0274), and the panoramic x-ray (D0330) provided on July 7, 2020. 
 
You asked the Plan to pay for the dental services. You say that the dental office advised they accepted your 
plan. You say that your plan did not verify if the dentist was in network. You say that you do not want to pay 
this bill. You also say that you are on a fixed income. The Plan denied your request. The Plan says the provider 
in this case is not a network provider. The Plan also says care that you receive from an out of network dental 
provider is not covered. 
 
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, care that you receive from an out of 
network dental provider is not covered. Therefore, we decided that the Plan does not have to pay for the oral 
evaluation (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and the panoramic x-ray (D0330) provided 
on July 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an inpatient hospital stay provided from 
March 26, 2020, to April 16, 2020. 
 
You asked the Plan to waive the coinsurance for inpatient stay. You say that you were informed by one of the 
hospital staff that this facility was in-network. The Plan denied your request. The Plan says the coinsurance 
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% 
coinsurance for out-of-network inpatient stay. At the time this claim was processed, $1,494.97 of the $5,100 
combined maximum out-of-pocket amount had been met. The allowed amount of this claim is $26,066.05, 
resulting in a coinsurance obligation of $3,605.03 because this amount met the $5,100 total combined 
maximum out-of-pocket amount for 2020. 
 
You have been asked to pay 40% coinsurance for inpatient stay, up to a maximum out-of-pocket amount of 
$5,100. 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 coinsurance for an inpatient hospital stay provided from March 26, 2020, to April 16, 2020.   
 
 
 
Your complaint regarding receiving inaccurate information about the network status of this hospital is 
considered to be a grievance. We does not have the jurisdiction to address grievances. 
Please contact the Plan for more information about your grievance.