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

We decided that the Plan does not have to waive the copayments for the podiatry visit and the ultrasound therapy provided on April 18, 2017 and April 20, 2017. 
 
You asked the Plan to waive the copayments for the podiatry visit and the ultrasound therapy. You say that you have already paid this bill. 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 $50 copayment for each in-network Medicare-covered visit.  
 
You have been asked to pay a total of $58.44 copayment for the podiatry visit and the ultrasound therapy. The podiatry visit and the ultrasound therapy fall within the "Podiatry Services" benefit category. See chart below. 
 
Date of Service Service Allowed Amount Copayment Member Liability 
April 18, 2017 Podiatry visit $49.79 $50.00 $49.79 
April 20, 2017 Ultrasound therapy $8.65 $50.00 $8.65 
Total    $58.44 
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 copayments for the podiatry visit and the ultrasound therapy provided on April 18, 2017 and April 20, 2017.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on March 6, 2020. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you weren't previously charged for lab testing. You say that your visit should be a $0 copayment. The Plan denied your request. The Plan says the copayment applied correctly. 
 
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 $5 copayment for diagnostic lab services and diagnostic procedures and tests.  
 
You have been asked to pay a $5 copayment for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 laboratory services provided on March 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for fixed-Wing air ambulance transport (A0430, A0426)
provided August 12, 2019.
You asked the Plan to pay for the air ambulance services. You say that the air ambulance was medically
necessary for transport back to a hospital closer to your home. The Plan denied your request. The Plan says air
ambulance services are only covered for transport to the closest appropriate hospital.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your
medical condition is such that transportation by ground ambulance is not appropriate.
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 air ambulance services. Our reviewer
says that coverage criteria has not been met. Our physician reviewer found the enrollee was stable and the
enrollee was not transported to the closest appropriate facility.
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 air ambulance services have not been met. Therefore, we decided that the
Plan does not have to pay for fixed-Wing air ambulance transport (A0430, A0426) provided August 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray rendered on January 13, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. There is no documentation to support the billing of more than one unit each of codes 73060-26-LT and 73060-26-RT. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray rendered on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 9, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the facility and provider are both 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 physician services provided on December 9, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for spherocylinder, trifocal lens (V2303) progressive lens (V2781) deluxe lens feature (V2702) polycarbonate lens (V2784) purchased January 23, 2020. 
 
You asked the Plan to waive the copayment for the vision services. You say that you received your EOB and it shows that a line was denied and you want to know why. You read the EOC and it says that the plan would pay up to $300 and you want the unpaid charges covered. The Plan denied your request. The Plan says this claim processed correctly and the correct cost share was 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 the plan pays up to $300 every 12 months for eyeglasses, frames, lenses or contact lenses from an in-network provider.  
 
You have been asked to pay $120. The provider billed $420. The plan applied the $300 for the eye wear benefit. Therefore, the $120 balance is your responsibility. The vision services fall 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 spherocylinder, trifocal lens (V2303) progressive lens (V2781) deluxe lens feature (V2702) polycarbonate lens (V2784) purchased January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for comprehensive oral exam (D0150) provided September 17, 2019. 
 
You asked the Plan to pay for the dental services. You say that assuming the $750 amount was correct and $275 has been paid already then you should have received $475 not $366.68 that you received. The Plan denied your request. The Plan says that Medicare policy does not cover this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The health plan contract though not clear, does say that oral exams are covered. In this case the plan has failed to provide any information on the basis of the denial. Therefore, we decided that the Plan has to pay for comprehensive oral exam (D0150) provided September 17, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care (99220) provided on July 13, 2018.
You asked the Plan to pay for observation care. You say that you did not received needed information to file
this claim timely. The Plan denied your request. The Plan says claims must be filed within a year of the date of
service.
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 observation care was not filed until October 3, 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 observation care (99220) provided on July 13, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy administration rendered on October 9, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 96413 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug. We find that CPT code 96413 is not supported in the medical record. Specifically, there is no documentation of the time over which the chemotherapy was administered. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the chemotherapy administration rendered on October 9, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an oral appliance for sleep apnea (E0486).
You asked the Plan to pre-approve the oral appliance. You say that the appliance is medically necessary. The
Plan denied your request. The Plan says that found the sleep study has confirmed sleep apnea and hypertension.
The appliance was ordered by a licensed dentist. The appliance is reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
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 pre-approve the oral appliance. Our reviewer says
that the oral appliance is medically necessary. Our physician reviewer found the sleep study has confirmed
sleep apnea and hypertension. The appliance was ordered by a licensed dentist. The appliance is reasonable and
necessary.
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 oral appliance have been met. Therefore, we decided that the Plan has to
pre-approve an oral appliance for sleep apnea (E0486).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided on January 15, 2020.
You asked the Plan to pay for the acupuncture services. The Plan denied your request. The Plan says in most cases you must receive care from in-network providers.
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 acupuncture 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 acupuncture services provided on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse your copayment for the cataract surgery provided on January 16, 2020.
You asked the Plan to reimburse your copayment for the cataract surgery. You say that you were informed you could use your Flex Benefit for your copay. The Plan denied your request. The Plan says that copays are not covered under your Flex Benefit.
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 $390 copayment for Medicare-covered visits to an ambulatory surgical center. You have been asked to pay a $390 copayment for the cataract surgery. The cataract surgery falls within the Medicare-covered visit to an ambulatory surgical center 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. The Plan contract also states the Flex Benefit is used for the purchase of non-Medicare healthcare items. A copayment is not a non-Medicare healthcare item. Therefore, we decided that the Plan does not have to reimburse your copayment for the cataract surgery provided on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2331) provided on January 13, 2020.
You asked the Plan to pay for the resin-based composite. You say that you assumed the dental plan had a $500 deductible and were assured this procedure was covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that you do not have a dental deductible for dental coverage.
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 resin-based composite (D2331) provided on January 13, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit provided on December 22, 2019.
You asked the Plan to waive the copayment for an outpatient hospital facility visit. You say that this was a follow-up visit and 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each outpatient surgery and or services provided at outpatient hospital facilities. You have been asked to pay the allowed amount of $115.54, which is less than the $250 copayment for an outpatient hospital facility visit. An outpatient hospital facility visit falls within the outpatient hospital services 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 outpatient hospital facility visit provided on December 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) and an electrocardiogram (93000) provided on November 27, 2019 by a provider that has opted out of Medicare.
You asked the Plan to pay for an office visit and an electrocardiogram. You say that these services were mandatory for a covered surgery. The Plan denied your request. The Plan says these services were provided by a provider who has 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. The provider of these services has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office visit (99214) and an electrocardiogram (93000) provided on November 27, 2019 by a provider that has opted out of Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on July 26, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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 99190 is assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour. We find that CPT code 99190 is not supported in the medical record. Specifically, these services were provided while the enrollee was inpatient in the hospital. Payment for this service is included in the Part A DRG payment to the facility. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of pump with oxygenator or heat exchanger services have not been met. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on July 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine (90715) provided on December 5, 2019.
You asked the Plan to pay for a Tdap vaccine. You say that this was prescribed by your doctor. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Tdap vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a Tdap vaccine. Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine (90715) provided on December 5, 2019.
Benefits for a Tdap vaccine may 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on January 3, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee was on hospice.
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 the physical therapy services rendered on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network providers available for these services.
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 an office visit provided on January 10, 2020 by an out of network (OON) provider.