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

We decided that the Plan does not have to reduce the copayment for the observation stay provided on November 28, 2020.

You asked the Plan to reduce the copayment for the observation stay. You say that you did not stay in observation and should only be charged an emergency room copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $300 copayment per visit for Medicare-covered outpatient observation services.

You have been asked to pay a $300 copayment for the observation stay. The observation stay falls within the "Outpatient hospital observation" benefit category. The medical record shows you were placed in observation. 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 the observation stay provided on November 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardioversion services provided on August 19, 2020 by a non-participating provider.
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 services were rendered by a non-participating 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 had network providers available who could have provided 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 cardioversion services provided on August 19, 2020 by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam (92014).

You asked the Plan to waive the copayment for the eye exam. You say that you should be charged the cost of a routine eye exam. The Plan denied your request. The Plan says the service provided was diagnostic, not routine, therefore the correct cost share 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 copayment for Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye. 

You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the Medicare-covered outpatient visit 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 eye exam (92014).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on November 16, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 had network providers available who could have provided the services at issue in this appeal. 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 the services provided to the enrollee by an out-of-network provider on November 16, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care provided on November 29, 2020.

You asked the Plan to pay for the initial hospital care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

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 initial hospital care provided on November 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (x2) (D0230) provided September 11, 2020, and the comprehensive periodontal evaluation (D0180) provided September 16, 2020.

You asked the Plan to pay for the intraoral x-rays and comprehensive periodontal evaluation. You say that you did not know you were provided uncovered services and cannot afford the cost. The Plan denied your request. The Plan says the services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, 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 intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (x2) (D0230) provided September 11, 2020, and the comprehensive periodontal evaluation (D0180) provided September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided December 3, 2020.

You asked the Plan to pay for the limited oral evaluation. You say that the service should be covered. The Plan denied your request. The Plan says the full dental allowance has already been issued for the year 2020 and therefore no payment by the Plan is due.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the limited oral evaluation and certain other dental services up to the $1,000 allowance.

We looked at the file and Medicare rules. The Plan provided documentation showing that the entire $1,000 dental allowance has already been applied to your dental claims in the year 2020. Based on this information, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided December 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the prostate cancer screening provided to you on November 23, 2020.

You asked the Plan to pay for the screening. The Plan denied your request. The Plan says this service was already paid for this year.

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 $0 copayment for a prostate cancer screening once every 12 months. 

Review of the file shows that you were provided a prostate cancer screening on November 23, 2020. The records show that you received a covered screening on March 6, 2020. The requested screening exceeds the benefit and is not covered. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the prostate cancer screening provided to you on November 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the face-down equipment.

You asked the Plan to pay for the face-down equipment. You say that this item was necessary for the enrollee's condition.The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item 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 pay for the face-down equipment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor supplies rendered on October 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 there is no valid physician order.

The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. 

We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 continuous glucose monitor supplies rendered on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 25, 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 was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99214) and an ultrasound (93970) provided on October 17, 2020.

You asked the Plan to waive the copayment for an office visit and an ultrasound. You say that there should only be one copayment for this visit. The Plan denied your request. The Plan says this processed 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's contract with the Plan clearly says that enrollees must pay a $20 copayment for advanced radiology services and for specialty physician's office visits. If advanced radiology services are performed in the provider's office during an office visit, the appropriate office visit copayment and advanced radiology service copayment will apply. 

The enrollee has been asked to pay a $20 copayment for an office visit and $20 for an ultrasound. 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 copayment for an office visit (99214) and an ultrasound (93970) provided on October 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services and the occupational services provided from February 11, 2019, to February 28, 2019.

You asked the Plan to pay for the skilled services. You say that the claim was initially submitted in October 2019. You say that the claim was submitted in a timely manner according to the Plan's guidelines. The Plan denied your request. The Plan says the claim was received more than 12 months after the dates 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 the skilled services was not filed until November 25, 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 physical therapy services and the occupational services provided from February 11, 2019, to February 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on November 17, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 had network providers available who could have provided the services at issue in this appeal. 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 the services provided to the enrollee by an out-of-network provider on November 17, 2020.
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 December 2, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you had to have the procedure done again and you do not believe you should be responsible for the second copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $45 copayment for each covered visit or consultation in an outpatient location with a specialist. You have been asked to pay a $45 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 the catheter insertion procedure was done during the 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 December 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound rendered on December 31, 2020.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was 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 $125 copayment for x-rays and ultrasounds at an outpatient hospital setting.

Review of the file shows that you had an ultrasound on December 31, 2020. You have been asked to pay a $125 copayment for these services. These services fall within the x-rays and ultrasounds at an outpatient hospital setting 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 ultrasound rendered on December 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for portable gaseous oxygen system (E0431) provided on January 9, 2021 by an out of network (OON) provider.

You asked the Plan to pay for portable gaseous oxygen system. You say that the item provided was medically necessary for the enrollee. The Plan denied your request. The Plan says prior authorization was not obtained from these services received from an OON provider.

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 had network providers available who could have provided 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 portable gaseous oxygen system (E0431) provided on January 9, 2021 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on December 9, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 had network providers available who could have provided the services at issue in this appeal. 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 the services provided to the enrollee by an out-of-network provider on December 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Lens spherocylinder bifocal 4.00d/.1 (V2203), Lens spherocylinder bifocal 4.00d/2.1 (V2204), Frames (V2020), and Progressive lens (V2781) provided January 18, 2019.
You asked the Plan to pay for the frames and lenses. You say that you were told the glasses were approved. The Plan denied your request. The Plan says the full allowance has already been applied to the claim and therefore no further payment is due.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers supplemental eyewear up to a $150 plan allowance. We looked at the file and the Plan's rules. The Plan provided documentation showing that the $150 allowance has already been applied to the frames and lens package. Based on this information, we decided that the Plan's rules for coverage of the frames and lenses have not been met. Therefore, we decided that the Plan does not have to pay for the Lens spherocylinder bifocal 4.00d/.1 (V2203), Lens spherocylinder bifocal 4.00d/2.1 (V2204), Frames (V2020), and Progressive lens (V2781) provided January 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit and the Part B injection provided on August 27, 2020.

You asked the Plan to waive the cost share for the office visit and the Part B injection. You say that this was a primary care visit and you do not feel like you owe this amount. The Plan denied your request. The Plan says you have been asked to pay 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 $15 copayment for in-network primary care physician (PCP) services (including Medicare-covered telehealth and urgently needed services) and 20% coinsurance for all other in-network drugs covered under Medicare Part B. 

You have been asked to pay a $15 copayment for the office visit. You have been asked to pay $1.34 which is 20% of the allowed amount for the Part B injection. The allowed amount is $6.72. ($6.72 x 20% = $1.34). The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Part B injection falls within the "Medicare Part B prescription drugs" benefit category.

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the office visit and the Part B injection provided on August 27, 2020.