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

We decided that the Plan does not have to pay for the radiology services (A9552) provided by an out of network provider.

You asked the Plan to pay for the radiology services. You say that the service should be covered.The Plan denied your request. The Plan says there were network providers available that could render this 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the radiology services (A9552) provided by an out of network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the bladder ultrasound test you had on August 24, 2020, and the cystourethroscopy procedure you had on September 10, 2020 at an outpatient hospital facility.
You asked the Plan to waive the cost sharing for the bladder ultrasound test and the cystourethroscopy procedure. You say that you thought these costs should be included in your follow-up specialty copayment. The Plan denied your request. The Plan says you were charged the correct cost sharing amounts for these services. The Plan says that because the allowed amounts for the bladder ultrasound test ($280.05) and the cystourethroscopy ($280.53) are less than your copayment obligations, you are responsible for these full amounts.
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 $350 copayment for outpatient diagnostic tests. You have been asked to pay up to a $350 copayment for the bladder ultrasound test and up to a $350 copayment for the cystourethroscopy procedure. The bladder ultrasound test falls within the outpatient diagnostic tests benefit category. The cystourethroscopy procedure falls in the outpatient surgery benefit category. The facility where you had both of these services is considered an outpatient hospital facility. 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 cost sharing for the bladder ultrasound test you had on August 24, 2020, and the cystourethroscopy procedure you had on September 10, 2020 at an outpatient hospital facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory services provided on September 8, 2020.
You asked the Plan to waive the deductible for laboratory services. You say that you disagree with the charges. 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. Your contract with the Plan says that there is a $198 deductible for outpatient diagnostic tests and therapeutic services and supplies. You received laboratory services on September 8, 2020. The record shows that you had only paid $76.99 toward the $198 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $5.34. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time laboratory services was received on September 8, 2020. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on September 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for an outpatient surgery provided by a participating provider on July 30, 2020.
You asked the Plan to reduce the copayment for an outpatient surgery. You say that you thought your copayment would be $50. You say that think this is too high. The Plan denied your request. The Plan says the correct copayment 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 $400 copayment for outpatient surgery/outpatient hospital facility. You have been asked to pay a $400 copayment for an outpatient surgery. An outpatient surgery falls within the outpatient surgery/outpatient hospital facility 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 for an outpatient surgery provided by a participating provider on July 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic blood pressure monitor provided on July 1, 2020.
You asked the Plan to pay for the automatic blood pressure monitor. You say that you need to take your blood pressure regularly. The Plan denied your request. The Plan says that this is not covered.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pay for the automatic blood pressure monitor provided on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 30, 2020.
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 Plan did 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 on July 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTadalafil tab.You asked the Plan to pre-approve Tadalafil tab. 

You say that you want the enrollee treated with this drug.The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Tadalafil tab.

Benefits for Tadalafil tabmay be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on July 1, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were told by the provider to reschedule and that you would not be charged for the visit. 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 $40 copayment per visit for an in-network specialist. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen for an office visit.
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 specialist office visit provided on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) and the complete series of x-rays (D0210) provided on August 28, 2020.
You asked the Plan to pay for the x-rays. You say that you were advised that you needed new x-rays done. You say that the previous x-rays were not sufficient and failed to show the abscess in your mouth. You also say that you needed this to help to save your life from sickness. The Plan denied your request. The Plan says full mouth or panoramic x-rays are covered once every 5 years. The Plan also says that the frequency limit has been exceeded.
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 frequency limit of 1 full mouth or panoramic x-ray every 5 years has been exceeded. The record shows that the Plan paid for a full mouth x-ray that you received on June 17, 2020. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) and the complete series of x-rays (D0210) provided on August 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for prothrombin time (85610) and collection of venous blood by venipuncture (36415) provided on August 17, 2020.
You asked the Plan to pay for prothrombin time and venipuncture. You say that the services should be covered. The Plan denied your request. The Plan says services were received from an out-of-network provider without prior authorization from the Plan.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of prothrombin time and venipuncture have not been met. Specifically, it is the responsibility of the requestor to provide sufficient information to determine whether payment is due. In this case, insufficient medical records were submitted, and therefore, could not be reviewed for medical necessity. The available records do not show that the services were urgent or emergent. Therefore, we decided that the Plan does not have to pay for prothrombin time (85610) and collection of venous blood by venipuncture (36415) provided on August 17, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on July 20, 2020.
You asked the Plan to waive the copayment for an emergency room visit. You say that you left before seeing a doctor. The Plan denied your request. The Plan says since an emergency room visit occurred, the correct copayment 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. Since an emergency room visit took place, the correct copayment has been applied. An emergency room 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 emergency room visit provided by a participating provider on July 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you need this to keep your surgical foot in place.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of abscess (D7511) provided on March 30, 2020.
You asked the Plan to pay for the dental service. You say that you paid $90 at the time you received the services. You say that you thought your insurance would cover the rest. You say that you received a bill for $140. You also say that the services you received were for emergency dental surgery. The Plan denied your request. The Plan says incision and drainage of abscess is not listed as a covered service. The Plan also says you did not attempt to contact the plan to verify your benefits prior to receiving the service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the incision and drainage of abscess (D7511) provided on March 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services received from an out of network provider on August 31, 2020.
You asked the Plan to pay for the dental services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an out of network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services received from an out of network provider on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on July 2, 2020.
You asked the Plan to pay for the vision services. You say that you should not be responsible for these charges. The Plan denied your request. The Plan says that these services are not payable.
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 does not cover vision services rendered by a provider who has formally "opted out" of the Medicare program are not covered or payable by the plan.. We looked at the file and the Plan's rules. The file indicates the provider has opted out of Medicare. 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 vision services provided on July 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pairing/cutting of hyperkeratotic lesion and debridement of nails provided on January 22, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese services. The Plan denied your request. The Plan says that the services were not emergent/urgent and were available within the network.Medicarerules 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 forthe pairing/cutting of hyperkeratotic lesion and debridement of nails provided on January 22, 2020 by an out of network (OON)provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lead wires (A4557) provided September 15, 2020.
You asked the Plan to pre-approve the lead wires. You say that the wires were medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.
The Plan must follow Medicare rules. Medicare rules say that replacement of lead wires more often than every 12 months would rarely be reasonable and necessary. We looked at the file and Medicare rules. The records show the unit was purchased within the last 12 months, and there is no clinical documentation showing why the wires require replacement. Based on this information, we decided that Medicare rules for coverage of the lead wires have not been met. Therefore, we decided that the Plan does not have to pre-approve lead wires (A4557) provided September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 11, 2020.
You asked the Plan to pay for the subsequent nursing facility care. 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 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 subsequent nursing facility care provided on August 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup battery for a continuous positive airway pressure (CPAP) device.

You asked the Plan to pre-approve backup battery. You say that you have electrical problems inthe area where you reside, so you need this battery backup.The Plan denied your request. The Plan says the denial of authorization for this device is correct, because this battery backup is not covered by Medicare.

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 CPAP which includes a power supply. A backup battery serves a duplicative purpose to your CPAP's existing power supply.A battery also serves a purpose that is not primarily medical in nature, is available to the general public, and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a backup battery for a continuous positive airway pressure (CPAP) device.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for a practitioner visit provided on June 3, 2020.
You asked the Plan to pay for practitioner visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the enrollee was enrolled in a hospice program on this date of service and therefore the Plan is not responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for a practitioner visit provided on June 3, 2020.