Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Visual field examination (92083) refraction services (92015) outpatient office visit (99214) and Scanning computerized ophthalmic diagnostic imaging (92133) provided August 3, 2020.

You asked the Plan to pay for the vision services. You say that you have paid your insurance payments every month and not one bill has been paid for. You are not going to go to the doctor's because the plan is not paying anything. The Plan denied your request. The Plan says services is not covered by the plan. Original Medicare does not cover for routine eye exams (eye refractions) for eyeglasses or contacts.

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 these services when refraction is covered when completed as part of a routine eye exam.

We looked at the file and the Plan's rules. The health plan contract says that vision coverage includes 1 routine exam per calendar year. Eye exam will include refraction and dilation. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for Visual field examination (92083) refraction services (92015) outpatient office visit (99214) and Scanning computerized ophthalmic diagnostic imaging (92133) provided August 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the prostate specific antigen (PSA) testing.

You asked the Plan to pay for these services. You say that you should not be liable. The Plan denied your request. The Plan says the services exceed the benefit limit.

The Plan must follow Medicare rules. The rules say that screening prostate specific antigen tests are covered at a frequency of once every 12 months for men who have attained age 50.

We looked at the file and Medicare rules. The file shows that you had a PSA screening that the Plan covered. The PSA screening was performed less than 12 months from your previously covered screening. 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 prostate specific antigen (PSA) testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services provided during an outpatient hospital stay.

You asked the Plan to waive the copayment for the specialist services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received services provided by a specialist during an outpatient hospital visit on the date of service at issue in this appeal. The Plan says that 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 $50 copayment for specialist services provided during an outpatient clinic visit. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services provided by a specialist during an outpatient hospital visit. You have been asked to pay a $50 copayment for the specialist services. The specialist services fall 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 the specialist services provided during an outpatient hospital stay.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on June 9, 2020.

You asked the Plan to pay for the durable medical equipment. 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.

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 for the durable medical equipment provided on June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944).

You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit under your dental policy.

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 item provided is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal guard (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the coinsurance for the Darbepoetin Alpha injection (J0881) provided on August 13, 2020.

You asked the Plan to waive or reduce the coinsurance for the drug injection. You say that you need to have these injections regularly and the cost is too high. The Plan denied your request. The Plan says Part B drugs are subject to 20% coinsurance.

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% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay 20% coinsurance for the drug injection. The Plan's allowed amount (the total amount the provider is allowed to be paid) for the Darbepoetin Alpha injection is $1,135.80 ($1,135.80 x 20% = $227.16). A drug 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 or reduce the coinsurance for the Darbepoetin Alpha injection (J0881) provided on August 13, 2020.

Your complaint about the coinsurance being too high in cost 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 unspecified preventive procedures (D1999).

You asked the Plan to pay for the dental services. You say that you are appealing the denial of dental services that the insurance plan had ended. The insurance in the past is the same as you have this year and have continued to make your monthly payments on time. The Plan denied your request. The Plan says this service is not covered under the plan benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Services not listed is not covered by the plan.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for unspecified preventive procedures (D1999).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided by a participating provider.

You asked the Plan to waive the deductible for an office visit. You say that you verified this provider was in-network. The Plan denied your request. The Plan says the correct deductible amount has been 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 $975 deductible for physician/practitioner services. 

You have been asked to pay a $975 deductible for an office visit. an office visit falls within the physician/practitioner 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. The total amount you are being asked to pay is $68.11. Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share applied for the injection of a drug or substance into a vein for therapy, diagnosis, or prevention (96374) and the Ferric carboxymaltose injection (J1439) provided on May 6, 2020.

You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the services provided.

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 each Medicare-covered Part B drug. Additionally, for the administration of that drug you will pay the cost-sharing that applies to primary care provider services, specialist services, or outpatient hospital services. Enrollees must pay a $40 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. 

You have been asked to pay $202.82 for the Plan allowed amount of $832.50 for the drug x 20% coinsurance, which equals $166.50. Additionally, the specialist copayment of $36.32 applies. This is the Plan allowed amount for the injection of the drug by the specialist, which is less than the applicable copayment. 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 applied for the injection of a drug or substance into a vein for therapy, diagnosis, or prevention (96374) and the Ferric carboxymaltose injection (J1439) provided on May 6, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out of network provider on August 10, 2020.

You asked the Plan to pay for the office visit. You say that you are requesting reimbursement for the services that were provided. The Plan denied your request. The Plan says the service could have been provided by an in-network 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 the office visit provided by an out of network provider on August 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery.

You asked the Plan to waive the copayment for the outpatient surgery. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient surgery provided in an outpatient hospital setting on the date of service at issue in this appeal. The Plan says that 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 $390 copayment for Outpatient hospital services.

We looked at the file, the Plan's contract and Medicare rule. The file shows that you received outpatient surgery provided in an outpatient hospital setting. You have been asked to pay a $390 copayment for the outpatient surgery. The outpatient surgery 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 the outpatient surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and the core build-up (D2950).

You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not a covered benefit under your dental policy.

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 items provided are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and the core build-up (D2950).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient psychiatric treatment.

You asked the Plan to waive the copayment for the outpatient psychiatric treatment. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient psychiatric treatment in a partial hospitalization structured outpatient program on the dates of service at issue in this appeal. The Plan says that the correct copayments have 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 $45 copayment for Partial hospitalization services. 

We looked at the file, the plan's contract and Medicare rules. The file shows that you received outpatient psychiatric treatment in a partial hospitalization structured outpatient program. You have been asked to pay a $45 copayment per day for the outpatient psychiatric treatment, totaling $675. The outpatient psychiatric treatment falls within the Partial hospitalization 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 the outpatient psychiatric treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided by an out of network (OON) provider.

You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

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 physician services provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from August 12, 2020, to August 14, 2020.

You asked the Plan to pay for the post stabilization services. You say that the inpatient services were medically necessary. The Plan denied your request. The Plan says the hospital failed to promptly notify the Plan of the admission and failed to provide sufficient clinical information regarding the enrollee's stability.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 

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 post stabilization services. Our reviewer says that the review has determined that by 4:30 p.m. on 8/12/2020, the enrollee was stable for ambulance transport with monitoring to a plan facility because the enrollee was ruled out for syncope. Our physician reviewer found the enrollee remained at his baseline mentation, was working with physical therapy, and remained hemodynamically stable and not orthostatic. A thoracic lumbar sacral orthosis brace was ordered and his CT of the brain was negative for delayed intracerebral hemorrhage. Renal masses were to be followed up as outpatient. The post-stabilization care services after 4:30 p.m. at the non-Plan facility were not medically necessary or reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. 

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 post stabilization services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided from August 12, 2020, to August 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the foot x-ray.

You asked the Plan to waive the copayment for these services. You say that you were told that there would be no copayments for services from a specialist. 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 $14 copayment for each in-network Medicare-covered standard x-ray service.

Review of the file shows that you received a foot x-ray. You have been asked to pay a $14 copayment for these services. These services fall within the in-network Medicare-covered standard x-ray service 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 waived a copayment for the specialist office visit but the Plan's website stated that cost shares for lab and diagnostic tests were not waived. Therefore, we decided that the Plan does not have to waive the copayment for the foot x-ray.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the elbow-wrist-hand orthosis (L3763) provided on August 31, 2020.

You asked the Plan to waive the coinsurance for the orthosis. You say that this was prescribed for you when you were treated for a broken elbow and you were not aware that you would be responsible for the cost. The Plan denied your request. The Plan says Durable Medical Equipment (DME) and related supplies, such as an orthosis, require 20% coinsurance.

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% coinsurance for DME and related supplies. 

You have been asked to pay 20% coinsurance for the orthosis. The Plan's allowed amount for the orthosis is $685.72 and you were asked to pay $137.14 ($685.72 x 20% = $137.14). An orthosis falls within the Durable Medical Equipment (DME) and related 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 coinsurance for the elbow-wrist-hand orthosis (L3763) provided on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5257, V5267).

You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not covered as they were provided by a non-participating hearing aid supplier.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.

We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of these items have not been met. Specifically, the Plan contract says that hearing aids must be provided by a participating hearing aid supplier. The hearing aids in this case were provided by a non-participating hearing aid supplier. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5257, V5267).