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

We decided that the Plan does not have to pay foran abdominal ultrasound (76705-26-59) provided on July 17, 2019.You asked the Plan to pay forthe abdominal ultrasound. You say that the billing is supported by the documentation.The Plan denied your request. The Plan says based on the documentation provided, the claim was processed correctly.The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Specifically, there are no medical records provided from the original procedure in this case (procedure code billed without the 59 modifier). Without additional medical records, the billing of modifier 59 is not supported.Based on this information, we decided that Medicare rules for coverage of the abdominal ultrasound have not been met.Therefore, we decided that the Plan does not have to pay foran abdominal ultrasound (76705-26-59) provided on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forwound care provided from May 7, 2019 through May 22, 2019.You asked the Plan to waive the copayments forwound care. You say that all of her visits were done in a treatment room not an operating room. You say that there should be a $0 balance.The Plan denied your request. The Plan says the copayments 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). The enrollee'scontract with the Plan clearlysays that enrollees must pay $300 for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility.The enrollee has been asked to pay $98.58, which is less than the standard$300 copaymentfor each wound carevisit. The total amount you owe is $492.90 ($98.58/visit x 5 visits = $492.90). Wound carefalls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. Wound care is considered a surgical procedure. This means that the enrolleehas been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrolleeagreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forwound care provided from May 7, 2019 through May 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 10, 2019 by an out of network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 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 medical services provided on June 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement forthe acupuncture (97810), massage therapy (97124), and unclassified drugs (J3490) provided by the "spa"  from February 27, 2019 to April 6, 2019.You asked the Plan to issue reimbursement forthese services. You say that you came down with the shingleswhile on board acruiselineout of the country and experienced extreme headaches and muscle pain. You say that you were taking Zarelto, therefore,you were unable to take pain medication due to risk factors. The cruise line doctor recommended acupuncture, massagetherapy, and topical medicines for your pain.The Plan denied your request. The Plan says emergent or urgently needed care services are covered while traveling outside the United States or itsterritories.This coverage is worldwide and limited to what is allowed to be provided in the United States. However, the services provided were not urgent or emergent in nature.The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Specifically, services provided outside of the United Statesare not a covered benefit of Medicare. The services do not meet criteria for coverage under the Plan supplemental worldwide urgent/emergent care benefit as there is no documentation provided to show that the services were rendered in an urgent/emergent care situation. There were no medical records provided for review in this case.Therefore, we decided that the Plan does not have to issue reimbursement forthe acupuncture (97810), massage therapy (97124), and unclassified drugs (J3490) provided by the"spa" from February 27, 2019 to April 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by on July 24, 2019.You asked the Plan to pay for the dental services. You say that you were not told your dentist was out of network.The Plan denied your request. The Plan says that you do not have out of network 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. The Plan does not cover the dental services when received out of network.We looked at the file and Medicare rules. The file indicates you received these services from an out of network provider. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pay for the dental services provided by on July 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the influenza vaccine and administration fee provided by opt out provider, on August 27, 2019.You asked the Plan to pay for the influenza vaccine. You say that you feel these services should be covered.The Plan denied your request. The Plan says the services received are not a covered benefit.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. This provider has opted out of the Medicare program. The file shows that entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay for the influenza vaccine and administration fee provided on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 7, 2019 by out of network provider. You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are not a covered benefit.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the office visit provided on August 7, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs provided on August 29, 2019 and September 4, 2019.
You asked the Plan to waive the coinsurance for the Part B drugs. You say that you should only owe 15% of the cost. You say that you feel you are being charged more. The Plan denied your request. The Plan says the coinsurance 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 15% of the cost for in-network Part B drugs. You have been asked to pay a total of $2,241.64, which is 15% of the cost for the Part B drugs.
Date of Service
Part B Drug
Allowed Amount
Coinsurance
Member Liability
August 29, 2019
Dexamethasone Sodium Phosphate Injection
$2.48
15%
$0.37
August 29, 2019
Diphenhydramine Injection
$0.86
15%
$0.13
August 29, 2019
Bendamustine Injection
$2,903.72
15%
$435.56
August 29, 2019
Obinutuzumab Injection
$5,700.24
15%
$855.04
September 4, 2019
Dexamethasone Sodium Phosphate Injection
$2.48
15%
$0.37
September 4, 2019
Diphenhydramine Injection
$0.86
15%
$0.13
September 4, 2019
Obinutuzumab Injection
$6,333.60
15%
$950.04
TOTAL:
$2,241.64
The Part B drugs 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 coinsurance for the Part B drugs provided on August 29, 2019 and September 4, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on August 25, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that you were admitted for observation so that insurance would pay for the stay. 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 emergency services at an in-network emergency room. You have been asked topay a $50 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you received observation services while in the emergency room.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 forthe emergency room visit provided on August 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient hospital evaluation provided on August 12, 2019.You asked the Plan to pay for inpatient hospital evaluation. You say that hospice denied payment because the enrollee was not in hospice on this date of service, therefore the Plan is responsible for payment.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 an inpatient hospital evaluation provided by on August 12, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0675, E0673).You asked the Plan to pay fora pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0675, E0673) is a preventive service.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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0675, E0673).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forInpatient Hospital Services provided September 3, 2019 to September 4, 2019 by "the hospital".You asked the Plan to waive the coinsurance forthe hospital services. You say that you weren't aware the hospital was out of network.The Plan denied your request. The Plan says the proper coinsurance 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 you must pay a 40% coinsurance for out-of-network inpatient hospital services. You have been asked to pay a 40% coinsurance for the hospital services. The hospital services fall within the out-of-network inpatient 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 coinsurance forInpatient Hospital Services provided September 3, 2019 to September 4, 2019 by "the hospital".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood pressure cuff purchased on July 18, 2019 from out of network provider.You asked the Plan to pay for the blood pressure cuff. You say that you request reconsideration for the cost of an inexpensive blood pressure monitor that you purchased.The Plan denied your request. The Plan says prior authorization is required for DME to be covered.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the blood pressure cuff purchased on July 18, 2019 from out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided by the doctor.
You asked the Plan to pay for the resin-based composite. You say that your doctor was determined that you needed an old and deteriorating filling replaced. The Plan denied your request. The Plan says coverage is not provided for a posterior filling according to your current dental plan. The Plan also says your current dental plan is a preventive only plan.
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 provided by the doctor.
Your complaint about being discouraged because the Plan is not reimbursing you for needed dental work 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 20, 2019 to August 21, 2019 by out of network provider, "the provider" .You asked the Plan to pay forthese services. You say that you were not aware the referral had expired.The Plan denied your request. The Plan says the services were rendered by a non-network provider without 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 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 medical services provided on August 20, 2019 to August 21, 2019 by out of network provider, "the provider"
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe injections provided from May 1, 2019 to June 24, 2019 by the out of network provider.You asked the Plan to pay forthe surgical services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says there was no evidence provided that the services were urgent or emergent in nature. The Plan also says the enrollee was not referred for the 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 provider in this case is not a network provider with the Plan. ThePlan 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 injections provided from May 1, 2019 to June 24, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on July 26, 2019.You asked the Plan to waive the deductible for the office visit. You say that you were informed the provider is in-network. You say that the Plan should pay the claim.The Plan denied your request. The Plan says the deductible applied correctly.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 your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Out-of-network services are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on July 26, 2019.Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on July 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by "the provider" on May 15, 2019.
You asked the Plan to pay forthe glucose monitor (E0607), test strips(A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that The Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid and proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by "the provider" on May 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora stress test (93017) provided May 14, 2019 by "the hospital". You asked the Plan to waive the copayment forthe stress test. You say that you were forced to perform the test.The Plan denied your request. The Plan says the record shows you willingly participated in the treadmill stress test.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 Outpatient Diagnostic Procedures. You have been asked to pay a $20 copayment for the stress test. The stress test falls within the Outpatient Diagnostic Procedures 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 fora stress test (93017) provided May 14, 2019 by "the hospital".