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

We decided that the Plan does not have to pay for the laboratory services provided on September 5, 2019.
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.
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 laboratory services provided on September 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial intraoral x-ray (D0220), an additional intraoral x-ray (D0230 x 3) provided on September 26, 2019.
You asked the Plan to pay for the 4 intraoral x-rays. You say that you advised you did not want x-rays. You say that you were told the x-rays were necessary for the dentist's analysis. You also say that you never got your cleaning. The Plan denied your request. The Plan says the dental services are not listed as 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, intraoral x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial intraoral x-ray (D0220), an additional intraoral x-ray (D0230 x 3) provided on September 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from July 1, 2019 to July 24, 2019.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the enrollee 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 plan.
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these ervices. Therefore, we decided that the Plan does not have to pay for physical therapy services provided from July 1, 2019 to July 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for LASIK (S0800).
You asked the Plan to pay for the LASIK. You say that the laser method was used to break up and remove the cataract lens in the right eye and is safer, more precise, causes less trauma, promotes faster healing and is capable of correcting slight astigmatism in the eye. The Plan denied your request. The Plan says LASIK (S0800) is not a covered procedure by Original Medicare or the Plan, nor was it authorized.
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 is not a covered benefit under Medicare or the Plan. Additionally, the record indicates that you signed and dated a consent form in which you acknowledge that LASIK was not covered. Therefore, we decided that the Plan does not have to pay for LASIK (S0800).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on July 19, 2019, from an out-of-network provider.
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied your request. The Plan says the member sought non-emergent/urgent services on his own with a non-contracting provider and did not all the primary care physician to request approval from the Plan which would have advised him where to seek the service.
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 to the enrollee on July 19, 2019, from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on August 5, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you should not be responsible for the copayment because the doctor did not prescribe anything. 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 $65 copayment for each Medicare-covered urgently needed care visit including Urgent Care centers. You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The record shows you were seen at the urgent care center.
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 visit provided on August 5, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 24, 2019 by the out of network provider.
You asked the Plan to pay for the psychiatric services (90785 and 90791). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member sought non-emergent services through a non-contracted 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 on July 24, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a tendon sheath incision provided by the provider on September 3, 2019.
You asked the Plan to waive the coinsurance for a tendon sheath incision. You say that you disagree with the charges. 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 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received a tendon sheath incision on September 3, 2019. The allowed amount is $721.10 and 20% of that is $144.22. You have been asked to pay the total coinsurance amount of $144.22 for a tendon sheath incision. A tendon sheath incision 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 coinsurance for a tendon sheath incision provided by the provider on September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on September 11, 2019.
You asked the Plan to waive the copayment for the laboratory work. You say that the laboratory work was a part of your routine physical. 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 $10 copayment for Medicare-covered laboratory tests. This copayment does not apply to blood draws or INR testing (anti-coagulant testing). You will only pay one copayment per day even if multiple lab tests are performed. You have been asked to pay a $10 copayment for the laboratory work. The laboratory work 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 the laboratory work provided on September 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (CPT Code 99233) provided to the enrollee on January 14, 2019.
You asked the Plan to pay for the services. You say that the physician rendered the service and is the correct provider. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. This code was reported with another evaluation and management service on the same day. According to Medicare rules, the evaluation and management service with the highest Medicare allowable will be reimbursed unless a prior claim with an evaluation and management service (with a lower Medicare allowable) for that date of service was been previously reimbursed. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (CPT Code 99233) provided to the enrollee on January 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered to the enrollee on May 29, 2019.
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 procedure code 99153 is not supported.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. The provider submitted a claim for procedure code 99153 with a place of service code of 22. This code has a PC/TC indicator of 3 and does not have separate PC payment. Payment is included in payment to the facility. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered to the enrollee on May 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a bronchoscopy provided on September 12, 2019 by the out of network provider.
You asked the Plan to pay for pathology services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that these services were not considered a medical emergency.
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 a bronchoscopy provided on September 12, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on October 15, 2019.
You asked the Plan to waive the deductible for office visit. You say that you had a "Welcome to Medicare" visit and it is your understanding that there is no cost-share for this visit. The Plan denied your request. The Plan says the deductible 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. Your contract with the Plan says that there is $183 deductible for in-network primary care office visit. This visit was provided due to multiple non-routine diagnoses; therefore, it is considered to be a diagnostic office visit with applicable cost-sharing. At the time this claim was processed, $0 of the $183 deductible had been met. The allowed amount of this claim is $107.52, resulting in a deductible obligation of $107.52. The item or service you asked the Plan to waive the deductible for falls within the benefit category Physician/Practitioner Services, Including Doctor's Office Visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $183 deductible for Physician/Practitioner Services, Including Doctor's Office Visits. This cost sharing is a contractual obligation that had not been met at the time office visit was received on October 15, 2019. Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on October 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen services provided on August 28, 2019 by an out of network provider.
You asked the Plan to pay for the portable gaseous oxygen system rental. You say that the enrollee did not notify you of any change and wants to stay with the practice. The Plan denied your request. The Plan says you did not have 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 did not pre-approve the item/service at issue. The record shows the enrollee lives in a skilled nursing facility and does not use oxygen. 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 oxygen services provided on August 28, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a multianalyte assay with algorithmic analysis provided on April 29, 2019.
You asked the Plan to pay for the multianalyte assay with algorithmic analysis. The Plan denied your request. The Plan says the enrollee 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 plan.
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 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 a multianalyte assay with algorithmic analysis provided on April 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 29, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the service 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 physician's services provided on July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on March 27, 2019.
You asked the Plan to waive the copayment for office visit. You say that all other visits to this doctor have been $20 copayments, so this visit should not be a $40 copayment. 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 $40 copayment for specialist office visit. You have been asked to pay $40 copayment for office visit. Office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 office visit provided on March 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 4, 2019.
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 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 physician services provided on September 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on March 20, 2019.
You asked the Plan to waive the copayment for an ambulance trip. You say that you did not like the people in
the ambulance. You say that you were only in the ambulance for 5 miles. The Plan denied your request. The
Plan says the correct copayment has been applied for the service that was 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 $325
copayment for ambulance services.
You have been asked to pay a $325 copayment for an ambulance trip. Since an ambulance trip was provided,
the correct copayment has been applied. An ambulance trip falls within the ambulance 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 an ambulance trip provided on March 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lens fitting (92310) provided on November 7, 2019.
You asked the Plan to pay for the contact lens fitting. You say that you have never had an additional charge for contact lens exam in the past except for your copayments and you should not be charged $30 now. The Plan denied your request. The Plan says this service is not covered under the benefits.
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 The plan covers prescription eyeglass lenses, eyeglass frames and contact lenses.. We looked at the file and the Plan's rules. the prescription eyewear rider specifically says that professional services for evaluation, fitting and follow up care for contact lenses is excluded. Based on this information, we decided that the Plan's rules for coverage of the contact lens fitting have not been met. Therefore, we decided that the Plan does not have to pay for the contact lens fitting (92310) provided on November 7, 2019.