Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for future physical therapy services.
You asked the Plan to waive the copayment for future physical therapy services. You say that you should not
have to pay for physical therapy because your injury originated in the hospital. The Plan denied your request.
The Plan says your copayment is a contractual obligation that cannot be waved.
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 $25
copayment for physical therapy services. You have been asked to pay a $25 copayment for future physical therapy services. 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 future physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that you are dissatisfied with your current treatment. The Plan denied your request. The Plan says out of network services are medically necessary when the plan's doctors are not able to provide the care 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 care that cannot be provided by network providers. 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 a referral to an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.You asked the Plan to pre-approve a continuous glucose monitor. You say that you want a continuous glucose monitor and supplies.The Plan denied your request. The Plan says the records show you are not insulin treated. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. You are not insulin treated so you do not meet the Medicare coverage criteria for a CGM. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on March 1, 2019.
You asked the Plan to pay for the ambulance services. You say that your claim was untimely because you did not have the correct insurance information for the enrollee. The Plan denied your request. The Plan says your claim was untimely.
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 ambulance services was not filed until March 4, 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 the ambulance services provided on March 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 5, 2019.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says that the claim was not filed timely.
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 dental services was not filed until April 29, 2019. 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 the dental services provided on January 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on February 29, 2020.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on February 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99214) provided on February 3, 2020 by an out of network (OON) provider.You asked the Plan to pay foran OON office visit. You say that you provided this service without analyzing the enrollee's coverage.The Plan denied your request. The Plan says this service was not authorized.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 forthe office visit (99214) provided on February 3, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network cardiology referral for the enrollee.You asked the Plan to pre-approve the referral. You say that this is medically necessary.The Plan denied your request. The Plan says the documentation presented does not indicate that this service is urgently or emergently 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 care that cannot beprovided by network providers.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 Plandoes not haveto pre-approvean out-of-network cardiology referral for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
You asked the Plan to pre-approve an automatic blood pressure monitor. You say that you need this to check your blood pressure. The Plan denied your request. The Plan says that this is not covered by Medicare or the Plan.
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 pre-approve an automatic blood pressure monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve dental anesthesia services for the enrollee.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says dental anesthesia is not a Medicare-covered benefit.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approve dental anesthesia services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service you had no idea what was happening to you and you felt nauseous and extremely hot. You say that you decided to call for an ambulance. You stated that while the paramedics were at your home you vomited and had a bowel movement. You say that you began to feel better and the paramedics evaluated you. After some questioning, it was determined that it was most likely food poisoning. You say that because of this, you declined going to the hospital. 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 March 15, 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for cone beam computed tomography (D0364) provided January
23, 2020.
You asked the Plan to pay for the dental services. You say that the provider's office is saying that you do not
have insurance that covered the work they did and now they are saying you owe them $1400. 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 cone
beam computed tomography (D0364) provided January 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on February 18, 2020.
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you received a mammogram screening and 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each basic imaging service. The medical records show that you received a diagnostic mammogram on February 18, 2020. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for a diagnostic mammogram. A diagnostic mammogram falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on February 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from November 6, 2019 to November 18, 2019.You asked the Plan to pay for the home health services. You say that this should be paid per-visit and not as episodic. This is billed correctly and should be paid.The Pla ndenied your request. The Plan says this claim is not on a valid TOB for Medicare home health coverage.The Plan must follow Medicare rules. Medicare rules say that home health claims are billed on one of the TOBs listed above.In this case, the claim is billed as TOB 0323. This is not one of the valid TOBs for Medicare payment of home health claims. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met.Therefore, we decided that the Plan does not have to pay for the home health services provided from November 6, 2019 to November 18, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on April 6, 2020.You asked the Plan to waive the coinsurance fora Medicare Part B drug. You say that you disagree with the increase in 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 Bdrug on April 6, 2020. The allowed amount is $382 and 20% of that is $76.40. The enrollee has been asked to pay the total coinsurance amount of $76.40 for a Medicare Part B drug. A Medicare Part B drug 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 fora Medicare Part B drug provided on April 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed and gel overlay.
You asked the Plan to pre-approve a semi-electric hospital bed (E0261) and gel mattress (E0185). You say that the enrollee needs a semi-electric hospital bed and gel mattress. The Plan denied your request. The Plan says the records do not support need for head elevation or frequent changes in body position.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. We looked at the file and Medicare rules. The record does not support a need for the head of the bed elevated, the need for attachments, or need for positioning of the body not feasible in an ordinary bed. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed (E0261) and gel mattress (E0185) have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed and gel overlay.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital stay, the outpatient hospital services, the laboratory services, the x-ray services, and the specialist office visits provided from March 6, 2018 to December 26, 2018.
You asked the Plan to waive the copayments for the inpatient hospital stay, the outpatient hospital services, the laboratory services, the x-ray services, and the specialist office visits. You say that you disagree with the amounts owed. The Plan denied your request. The Plan says the services have been processed correctly per your plan 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). Your contract with the Plan clearly says that you must pay a $20 copayment for each covered outpatient lab service, a $395 copayment per day, for days 1-4 for each inpatient hospital admission, a $200 copayment for each covered x-ray in the outpatient department of a network hospital or facility, a $250 copayment for covered radiology to diagnose a condition when you receive these services in an outpatient department of a network hospital or facility, and a $40 copayment for each covered specialist office visit. You have been asked to pay a $1,580 copayment for the inpatient hospital stay, a $250 copayment for the radiology outpatient hospital services, three- $20 copayments and a $4.38 copayment (since this was less than your $20 copayment requirement, you were charged the lesser amount) for the laboratory services, a $70.18 copayment and $75.47 copayment for the x-ray services (since this was less than your $200 copayment requirement, you were charged the lesser amount), and a $160 total copayment for the specialist office visits. 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 copayments for the inpatient hospital stay, the outpatient hospital services, the laboratory services, the x-ray services, and the specialist office visits provided from March 6, 2018 to December 26, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pseudo-aneurysm injection provided on February 5, 2020.
You asked the Plan to waive the copayment for the pseudo-aneurysm injection. You say that you should not be responsible for the copayment amount. 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 $325 copayment for surgical services at an in-network outpatient hospital facility. You have been asked to pay a $325 copayment for the pseudo-aneurysm injection. The pseudo-aneurysm injection falls within the "Outpatient surgery, including services 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 the pseudo-aneurysm injection provided on February 5, 2020.
Your complaint about the hospital failing to provide the doctors the proper supplies 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.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the nasal endoscopy provided on January 29, 2020.You asked the Plan to waive the coinsurance for the nasal endoscopy. You say that you were not told that the hospital was not a provider for your insurance. You say that the surgery center was no located at the hospital. 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 30% coinsurance for Medicare-covered surgery or other services provided to you at an out-of-network outpatient hospital, including but not limited to hospital orother facility charges and physician or surgical charges. You have been asked to pay $1,939.08 which is 30% of the allowed amount for the nasal endoscopy. The allowed amount is $6,463.30. ($6,463.30 x 30% = $1,939.08). The nasal endoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Center" benefit category. The record shows you were billed by an out-of-network outpatient hospital.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 the nasal endoscopy provided on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (D0383) provided March 3, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing the denial of reimbursement of the $244 you paid for the maxillofacial CT scan this is in preparation of the removal of your teeth for dental implants. 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. Per the plan contract only bitewing x-rays, complete series x-rays or panoramic x-rays are covered by the plan. 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 cone beam computed tomography (D0383) provided March 3, 2020.