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

We decided that the Plan does not have to pay for the polycarbonate lenses and tint provided on October 21,
2019.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says that this is not a
covered benefit.
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.
Though the Plan offers a vision benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
polycarbonate lenses and tint provided on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forwound debridement provided from October 25, 2019 through November 25, 2019.You asked the Plan to waive the copayment forwound debridement. You say that you were not informed you would have to pay a copayment for each visit.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 $250 copayment for each Medicare-covered outpatient hospital facility visit.You have been asked to pay a total of $732.98 for wound debridement. Date of ServiceServiceAllowed AmountStandard CopaymentMember LiabilityOctober 25, 2019Wound Debridement$667.03$250$250November 1, 2019Wound Debridement$236.99$250$236.99November 8, 2019Wound Debridement$236.99$250$236.99TOTAL:$732.98. Wound debridement 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 forwound debridement provided from October 25, 2019 through November 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Computed Tomography (CT) of the Abdomen and Pelvis (74176) provided on December 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the CT scan. You say that the services were medically necessary. The Plan denied your request. The Plan says there were 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 Computed Tomography (CT) of the Abdomen and Pelvis (74176) provided on December 3, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on October 30, 2019.You asked the Plan to pay forthe assembly and operation of a pump with oxygenator or heat exchanger. You say that this was a necessary service.The Plan denied your request. The Plan says payment for this service is included in the DRG.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 forthe assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on October 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on April 22, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that you should not have to pay for a procedure that was medical necessary. You say you cannot pay for it. 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 $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $295 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient Surgery and Other Medical 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 the colonoscopy provided on April 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Bone imaging (78306, A9561) provided December 19, 2019 by provider.You asked the Plan to pay for bone imaging. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim is a duplicate.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 code 78306, A9561 is not supported in the medical record. Specifically, the plan documentation shows the claim is a duplicate of a previously paid claim. Based on this information, we decided that Medicare rules for coverage of bone imaging have not been met.Therefore, we decided that the Plan does not have to pay for Bone imaging (78306, A9561) provided December 19, 2019 by provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the chewable Aspirin tablet, 324 mg, provided on January 16, 2020.
You asked the Plan to pay for the Aspirin. You say that you never self-administered any drugs while you were in the emergency room on January 16, 2020. You also say that you were given several baby Aspirin and had your blood drawn twice, in addition to a CT scan. The Plan denied your request. The Plan says Aspirin is a self-administered drug. The Plan says such drugs are not covered under Part B of Original Medicare.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 the chewable Aspirin tablet, 324 mg, provided on January 16, 2020.
Benefits for the Aspirin 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatmentwith an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have notbeen met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction provided on December 3, 2019.
You asked the Plan to pay for the refraction. You say that this should be covered because you had cataract surgery. The Plan denied your request. The Plan says that this is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the refraction provided on December 3, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from November 12, 2019 to November 29, 2019.You asked the Plan to pay forhome health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says payment is not allowed for this claim because the FIPS code is missing or invalid.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim has been submitted without the required FIPS and value codes.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from November 12, 2019 to November 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on December 16, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found.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/servicesat 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 foran office visit provided on December 16, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on January 15, 2020.You asked the Plan to pay forthe 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 forthe medical services provided to you by an out-of-network provider on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for pulp vitality tests (D0460) and cone beam computed tomography (CT) capture and interpretation (D0364) provided on December 4, 2019.
You asked the Plan to pay for the pulp vitality tests and the cone beam CT. You say that the services provided were medically necessary. You say that the in-network dentist you saw was not able to do a root canal and referred you to another facility. You say that a Plan rep confirmed that this dental provider was in-network. The Plan denied your request. The Plan says the two services which remain in dispute are not listed as covered 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. 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 pulp vitality tests (D0460) and cone beam computed tomography (CT) capture and interpretation (D0364) provided on December 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Asmanex inhaler for the enrollee.You asked the Plan to pre-approveAsmanex. The Plan denied your request. The Plan says a drug that you give yourself is not covered under the enrollee's Part B plan.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 pre-approvean Asmanex inhaler for the enrollee.Benefits for Asmanexmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ventolin HFA.You asked the Plan to pre-approvethe Ventolin HFA. You say that you would like reconsideration because the member has been using this drug with great success.The Plan denied your request. The Plan says this medication does not fall under the member's Medicare Part B coverage.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 pre-approveVentolin HFA.Benefits for the Ventolin HFAmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on November 6, 2019.You asked the Plan to pay forthe 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 forthe medical services provided to the enrollee by an out-of-network provider on November 6, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon October 25, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the planMedicare 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 did not pre-approve the physician's services. 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 physician's services provided on October 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the mepolizumab injection provided on
January 7, 2020.
You asked the Plan to waive the coinsurance for the injection. You say that The Plan denied your request. The
Plan says that you have a 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 a 20%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for the injection. The 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 for the mepolizumab
injection provided on January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on November 20, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says the orthosis is not supported by documentation from the referring physician.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There are no medical records supporting medical necessity. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650) have not been met.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) and the oral cancer screening (D0431) provided on December 5, 2019.You asked the Plan to pay forthe dental services. You say that you took extra precautions this time. You say that in the past you had this same issue and it resulted in an infection and further damage. You also say that you saved the plan money by having this service and preventing further medical complications.The Plan denied your request. The Plan says 2 oral exams are covered per calendar year. The Plan says that the benefit limit for oral exams has been exceeded. The Plan also says that the oralcancer screening is not a covered service.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 and oral exams are a covered service, the benefit limit has been exhausted. The record shows that the Plan paid for the oral exams that you received on May 14, 2019 and October 21, 2019. Additionally, the oral cancer screening isnot among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) and the oral cancer screening (D0431) provided on December 5, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140) and the root canals (D3330 x 2) provided form April 3, 2019 to April 25, 2019.
You asked the Plan to pay the in network rate for the root canals. You say that the dental services were necessary to your general health. You also say that your disability income will not be able to cover these high amounts. The Plan denied your request. The Plan says root canals are not a covered service.
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, root canals are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140) and the root canals (D3330 x 2) provided form April 3, 2019 to April 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory testing provided by hospital on August 8, 2019.You asked the Plan to pay forlab tests. You say that you are appealing.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not the testing billed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met.Therefore, we decided that the Plan does not have to pay forlaboratory testing provided by Hospital on August 8, 2019.