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

We decided that the Plan does not have to pay for the laboratory services provided by out of
network provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered 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 laboratory services provided
by out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay foroccupational therapy services (97165, 97542, 97530, and 97110) provided on July 4, 2019 to July 14, 2019 by out of network provider,"the provider" .You asked the Plan to pay foroccupational therapy services. You say that these services were medically necessary.The Plan denied your request. The Plan says these services were not authorized.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 nota 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 foroccupational therapy services (97165, 97542, 97530, and 97110) provided on July 4, 2019 to July 14, 2019 by out of network provider, "the provider".
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plandoes not haveto pay forpsychiatry services provided to the enrollee on May 2, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysan authorization was not obtained.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 Plandoes not haveto pay forpsychiatry services provided to the enrollee on May 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on September 5, 2019 by an out of network provider.You asked the Plan to pay forthe office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered 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/serviceat 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 office visit provided on September 5, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency department visit and related services provided to "the beneficiary" on September 23, 2016.You asked the Plan to pay forthe emergency department visit and related services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed untimely.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 onecalendar year after the date of service.Review of the file shows that the plan sent a check reversal on January 29, 2019. The last day of the 6th calendar month following the month in which the error was rectified is the last date to file a corrected claim.The record shows that a claim for the emergency department visit and related services was not filed until August 8, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe emergency department visit and related services provided to "the beneficiary" on September 23, 2016.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on August 6, 2019.You asked the Plan to pay for the dental services. You say that this should be reprocessed and paid.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 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 forthe dental services provided on August 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pay forvaccine services received on March 15, 2019.You asked the Planto pay forthe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the services.Therefore, we decided that the Plandoes not haveto pay forvaccine services received on March 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe specialist office visit or the Part B drug injection provided on July 16, 2019.You asked the Plan to waive the cost share forthespecialist office visit and the Part B drug injection. You say that that the liability has doubled since the last time you had the service. You say you cannot afford this amount.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 $35 copayment per visit for an in-network visit with a specialist and 20% coinsurance for each in-network Medicare-covered Part B drug. You have been asked to pay a total of $637.00 for the specialist office visit and the Part B drug injection. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Part B drug injection falls within the "Medicare Part B prescription drugs" benefit category. See chart below.
Date of ServiceServiceAllowed AmountCoinsurance/CopaymentMember LiabilityJuly 19, 2019Specialist office visit$87.65$35.00$35.00July 19, 2019Part B drug injection$3,010.0020%$602.00Total$637.00This 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 forthe specialist office visit or the Part B drug injection provided on July 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for unspecified removable prosthodontic procedure, customized dentures (D5899x2) provided by the doctor.
You asked the Plan to pay for the customized dentures. You say that you have dentures that you cannot wear and is being denied an appointment for adjustments. The Plan denied your request. The Plan says these services are not a covered benefit.
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 unspecified removable prosthodontic procedure, customized dentures (D5899x2) provided by the doctor.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora computed tomography (CT) scan of the head or brain (70450) provided on July 10, 2019. You asked the Plan to pay for the CT scan of the head or brain. You say that the services were provided and payment should be rendered.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, the medical records provided do not corroborate the rendering provider listed in the claim. Based on this information, we decided that Medicare rules for coverage of the CT scan of the head or brain have not been met.Therefore, we decided that the Plan does not have to pay fora computed tomography (CT) scan of the head or brain (70450) provided on July 10, 2019.
Appeal type: Testing
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 these 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 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 podiatry services provided by an out-of-network provider on June 21, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.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 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 podiatry services provided by an out-of-network provider on June 21, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit charge for services provided on July 12, 2019.You asked the Plan to pay for the office visit charge. You say that you should not be responsible for this charge since it is required yearly.The Plan denied your request. The Plan says Medicare does not pay for this service when provided by a chiropractor as it only pays for the manual manipulation itself. As such, this charge was correctly denied.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the office visit charge for services provided on July 12, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visits provided on July 15, 2019 and July 17, 2019.

You asked the Plan to waive the copayment for the urgent care visits. You say that your primary care physician was unavailable. You say that the antibiotics didn't work so you had to return a second time. 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). Your contract with the Plan clearly says that you must pay a $65 copayment per visit for Medicare-covered urgently needed services.

You have been asked to pay a $65 copayment for each urgent care visit. The total amount you owe is $130 ($65/visit x 2 visits = $130). The urgent care visits fall within the "Urgently needed 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 urgent care visits provided on July 15, 2019 and July 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network biopsy services provided on January 11, 2019. You asked the Plan to pay for this service. You say that this service should be covered by the Plan.The Plan denied your request. The Plan says you did not have prior authorization for 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 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 out of network biopsy services provided on January 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self administered drugs provided from August 14, 2019 to
August 15, 2019 by the Medical Center.
You asked the Plan to pay for self administered drugs under Medicare Part B. You say that this claim should be
paid. The Plan denied your request. The Plan says payment for self administered drugs must be submitted to
your Medicare Part D or pharmacy carrier.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self administered drugs provided
from August 14, 2019 to August 15, 2019 by the Medical Center.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-spinal manual manipulation services provided from June 28, 2019 to August 28, 2019 billed with code 98943.You asked the Plan to pay for the non-spinal manipulation. You say that you feel that this should be covered.The Plan denied your request. The Plan says all spinal manipulation was approved for payment; however, non-spinal services were correctly denied.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the non-spinal manual manipulation services provided from June 28, 2019 to August 28, 2019 billed with code 98943.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 26, 2018 by out of network provider, the doctor.
You asked the Plan to pay for electrocardiogram. You say that you are fully aware of the timely filing limits, however you are requesting a one-time courtesy for payment. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.
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 on September 26, 2018 by out of network provider, the doctor.
Appeal type: ER
Decision: Favorable

We decided that the Plan ha sto pay for the emergency department (ED) services provided on August 31, 2019 billed with 99282-25.You asked the Plan to pay for the ED services. You say that these were two separate visits where the enrollee presented with distinct issues.The Plan denied your request. The Plan says that code 99285 was already reported and paid for this date. The second visit is not separately payable.The Plan must follow Medicare rules. Medicare rules say that Column I/Column II pairs with a modifier indicator of 1 may both be paid if a clinically appropriate modifier is used.In this case, the enrollee was seen for chest pain around midnight and was discharged in stable condition when symptoms resolved. He returned at 8AM with increased abdominal pain worse than before. The second visit was billed with the -25 modifier meaning that it is a separate and distinct service. This is corroborated by the records.Therefore, we decided that the Plan has to pay for the emergency department (ED) services provided on August 31, 2019 billed with 99282-25.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the office visit, and chiropractic manipulations for 5 regions provided from July 31, 2019 to August 23, 2019 by the out of network provider.You asked the Plan to reimburse you for the chiropractic care. You say that you needed the services due to a fall. You also say that you do not have a primary care physician.The Plan denied your request. The Plan says authorization was not obtained before you received the services. The Plan says that you self-directed for the services. The Plan also says there is no evidence that the services were urgent or emergent.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 reimburse you 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. The Plan has network providers availablewho 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 reimburse you for these items/services.Therefore, we decided that the Plan does nothave to reimburse you forthe office visit, and chiropractic manipulations for 5 regions provided from July 31, 2019 to August 23, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on July 8, 2019.You asked the Plan to waive the copayment for the eye exam. You say that this was a routine eye exam. You say that there should be no reason this was billed as medical.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye.You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show that this was a medical eye exam. 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 provided on July 8, 2019.