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

We decided that the Plan does not have to waive the copayment for an epidural injection provided.
You asked the Plan to waive the copayment for outpatient surgery. You say that you are on a fixed income but need these injections every 3 to 4 months. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $275 copayment for outpatient surgery at an outpatient hospital facility. You have been asked to pay $275 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including Services Provided 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 an epidural injection provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee.
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 not billed with the required clinical trial number.
The Plan must follow Medicare rules. The rules say that it is mandatory to report a clinical trial number on
claims for items/services provided in clinical trials/studies/registries, or under CED
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required clinical
trial number. 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 services rendered to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pre-fabricated post and core (D2954) provided.
You asked the Plan to pay for the dental services. You say that you are appealing the denial of the dental claim because your age of 76 years old and your fixed income was not taken into consideration for the treatment recommended. The Plan denied your request. The Plan says the plan does not provide benefits for a provider that has opted out of Medicare. Per records, the doctor had opted out of Medicare for the month of May 2019.
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 by the doctor. This provider has opted out of the Medicare program. The file shows that the doctor entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the pre-fabricated post and core (D2954) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by out of network provider,.
You asked the Plan to pay for specialist services. You say that you were assured the doctor participated in your insurance plan. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network providers available.
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 medical services provided by out of network provider.
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 (99190) provided.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger.. You
say that this was a medically necessary service. The Plan denied your request. The Plan says payment of this
service is included in the DRG payment.
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 2019 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 pump with oxygenator or heat exchanger (99190)
provided.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance transports provided from July 29, 2019 through September 4, 2019.You asked the Plan to waive the copayments for the ambulance transports. You say that this was the safest way to be transported. You say that you disagree with the costs.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's contract with the Plan clearly says that enrollees must pay a $300 copayment per one-way trip for emergency ambulance services and non-emergency ambulance services.The enrollee has been asked to pay a total of $1,578.60 for the ambulance transports. The ambulance transports fall within the "Ambulance services" 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 copayments for the ambulance transports provided from July 29, 2019 through September 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a refraction provided.
You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says that Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts.
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. We looked at the file and Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for a refraction provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided to enrollee on March 13, 2018.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says these are considered routine 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 rendering 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 podiatry services provided to enrollee on March 13, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe allergy injection provided by the provider on August 30, 2019.You asked the Plan to waive the coinsurance forthe allergy injection. You say that you do not think you should be paying a cost share. 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 20% of the total cost for other Medicare-covered Part B prescription drugs. You have been asked to pay a total cost share amount of $28.84 which is 20% of the allowed amount for the allergy injection. The total allowed amount is $144.17. ($144.17 x 20% = $28.84). The allergy 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 coinsurance forthe allergy injection on August 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no documentation of clotting disorder or HIV.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the records from the treating provider were obtained and do not indicate the member was undergoing
coronary intervention with the initiation of Plavix nor taking a tricyclic or tetrabenazine. There is no
documented clotting disorder or diagnosis of HIV. The review has determined that the items/services at issue in
this case medically 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 services have not been met. Therefore, we decided that the Plan does not
have to pay for lab services provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar sacral orthosis and shoulder/arm orthosis provided to the enrollee on June 28, 2019.You asked the Plan to pay forthe orthoses. The Plan denied your request. The Plan says that the request is not a covered benefit according to your plans.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe lumbar sacral orthosis and shoulder/arm orthosis provided to the enrollee on June 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not have to pay forthe continuous intraoperative neurophysiology monitoring and supplies provided by the provider on July 26, 2019.You asked the Plan to pay forthe continuous intraoperative neurophysiology monitoring and supplies. Yousay that the Plan should pay this claim.The Plan denied your request. The Plan says CPTcodes 95938, 95870, 95937 need a modifier, 95940 is an add on code with no base code, and A4215 and A4290 would be provided by the facility.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 95940, 95938, 95870, 95937, A4215, A4290 were billed incorrectly. Based on this information, we decided that Medicare rules for coverage of the continuous intraoperative neurophysiology monitoring and supplies have not been met.Therefore, we decided that the Plan does not have to pay forthe continuous intraoperative neurophysiology monitoring and supplies provided on July 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ECG provided by the practice on August 13, 2019.You asked the Plan to waive the copayment for an ECG. You say that you disagree with the charges because they were part of a pre-admission.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 $100 copayment for outpatient diagnostic testing. You have been asked to pay the allowed amount of $8.76, which is less than the $100 copayment for an ECG. An ECG 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 an ECG provided by the practice on August 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus vaccine (90715 and 90471) provided on August 11, 2019.
You asked the Plan to pay for the tetanus vaccine (90715 and 90471). You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered under the enrollee's Medicare Part B benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine (90715 and 90471). The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the tetanus vaccine (90715 and 90471). Therefore, we decided that the Plan does not have to pay for the tetanus vaccine (90715 and 90471) provided on August 11, 2019.
Benefits for the tetanus vaccine (90715 and 90471) 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient psychotherapy services provided on October 31, 2019.You asked the Plan to waive the copayment for the outpatient psychotherapy services. You say that you feel you should not be responsible for this cost share amount. You say that you would like the plan to reconsider your request.The Plan denied your request. The Plan says you received outpatient mental health care on the date of service at issue in this appeal. The plan states the correct copayment has applied per your contract with the plan.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 Outpatient mental health care. We looked at the file and Medicare rules. The file shows that you received outpatient psychotherapy services on October 31, 2019. You have been asked to pay a $40 copayment for the outpatient psychotherapy services. The outpatient psychotherapy services fall within the Outpatient mental health 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 the outpatient psychotherapy services provided on October 31, 2019.Your complaint about feeling that you should be reimbursed because the provider cancelled you as a patient 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 waive the coinsurance forthe gel-one injection (J7326) provided on July 12, 2019.You asked the Plan to waive the coinsurance forthe gel-one injection (J7326). You say that you would like the plan to reconsider your request.The Plan denied your request. The Plan says you received a gel-one injection on the date of service at issue in this appeal. The plan states the correct coinsurance has applied per your contract with the plan.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% coinsurance for Medicare Part B Prescription Drugs. We looked at the file and Medicare rules. The file shows that you received a gel-one injection on July 12, 2019. You have been asked to pay a 20% coinsurance for the gel-one injection (J7326), totaling $226. The gel-one injection (J7326) 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 forthe gel-one injection (J7326) provided on July 12, 2019.Your complaint about needing an explanation for why you were not charged for the first gel-one injection 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services provided.
You asked the Plan to waive the copayment for physical therapy services. You say that you cannot afford this bill. The Plan denied your request. The Plan says these services 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). Your contract with the Plan clearly says that you must pay $40 copayment for each physical, occupational, or speech language therapy visit. You have been asked to pay $40 for three physical therapy visits, totaling $120. 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 physical therapy services provided.
Your complaint about the payment status of this bill 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deluxe frameand progressive lenses provided on January 29, 2019.You asked the Plan to pay for the deluxe frame and progressive lens. The Plan denied your request. The Plan says eyeglass upgrades are not a covered benefit.The Plan must follow Medicare rules.Medicare rules say that deluxe frames are non-covered. Medicare rules say that progressive lenses are non-covered. The contract with the Plan says that coverage for eyeglasses after cataract surgery includes standard frames and lenses as defined by Medicare; any upgrades are not covered (including, but not limited to, deluxe frames, tinting, progressive lenses or anti-reflective coating). We looked at the file and Medicare's rules. Medicare says thatdeluxe frames and progressivelenses are non-covered. Therefore, we decided that the Plan does not have to pay forthe deluxe frameand progressive lenses providedon January 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe secondpair of eyeglasses provided by "the provider" on July 3, 2019.You asked the Plan to pay forthe second pair of eyeglasses. You say that you were out of the area and broke your glasses so since you could not see clearly the Plan should pay for the exam and eyeglasses.The Plan denied your request. The Plan says your Vision Benefit is for one pair of lenses and frames every two years.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. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the second pair of eyeglasses have not been met.Therefore, we decided that the Plan does not have to pay forthe secondpair of eyeglasses provided by"the provider" on July 3, 2019.