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

We decided that the Plan does not have to pay for transportation costs to and from treatments.
You asked the Plan to pay for the transportation costs. You say that without being reimbursed for transportation you will not be able to continue treatment. The Plan denied your request. The Plan says mileage reimbursement is not a covered benefit.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of the transportation costs have not been met. Therefore, we decided that the Plan does not have to pay for transportation costs to and from treatments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic procedures provided on February 3, 2020 and
February 12, 2020.
You asked the Plan to pay for the therapeutic procedures. The Plan denied your request. The Plan says that the
Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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 therapeutic procedures provided on February 3, 2020 and
February 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on July 2, 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 71045-26 is not separately payable.
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately
payable when furnished in different payment localities.
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different
payment localities. 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 chest x-ray rendered on July 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on October 30, 2019.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory 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 for the assembly and operation of a pump with an 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 cost for the stent placement, office visit and ultrasound
provided on May 3, 2019.
You asked the Plan to waive the cost for the stent placement, office visit and ultrasound. You say that the
hospital shouldn't have any claim for further payments connected to this procedure. The Plan denied your
request. The Plan says the cost share 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 20%
coinsurance for all other services for in-network outpatient hospital services and a $40 copayment per provider
per day for an in-network specialist.
You have been asked to pay a total of $2,163.57 for the stent placement, office visit and ultrasound.
Service Provider Allowed Amount Standard Cost Member Liability
Stent Placement Doctor $632.32 20% $126.46
Office Visit Doctor $116 $40 $40
Ultrasound Doctor $41.21 20% $8.24
Stent Placement Hospital $11,379.80 20% $1,988.87-Met Max
OOP
TOTAL: $2,163.57
The stent placement and ultrasound fall within the "Outpatient hospital services" benefit category. The office
visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The
records show that the services were performed. 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 for the stent
placement, office visit and ultrasound provided on May 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve speech pathology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve speech pathology services. You say that this machine is necessary for you. The Plan denied your request. The Plan says these services can be provided in-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve speech pathology services to be provided by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on January 13, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you did not received any services at the emergency room and that you were only given a prescription for pain. You say you should not be responsible for the copayment. 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 $120 copayment for Medicare-covered emergency room visits. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $120 copayment for the emergency room visit.
You have been asked to pay a $87.65 copayment for the emergency room visit. The emergency room visit falls within "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit provided on January 13, 2020.
Your complaint about being misdirected by the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit copayment and Magnesium Citrate provided on March 4, 2020.You asked the Plan to pay foran office visit copayment and Magnesium Citrate. You say that you should be reimbursed because you did not have a colonoscopy.The Plan denied your request. The Plan says this processed correctly.The rules say a planmust 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 copayment for each Medicare-covered specialist visit. The rules also say that Medicare Part B generally does not pay for self-administered drugs.You have been asked to pay a $20 copayment for an office visit. 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. You have also been asked to pay $4 for Magnesium Citrate, a self-administered drug. The self-administered drugs requested here are not among the types which arecovered by Medicare Part B.Therefore, we decided that the Plan does not have to pay foran office visit copayment and Magnesium Citrate provided on March 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive thecopayment foran inpatient hospital stay provided from February 19, 2020 to February 21, 2020.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you disagree with the charges because you were told the Plan would fully cover 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 a $200 copayment for days 1-7 for inpatient hospital care. You had an inpatient hospital stay from February 19, 2020 to February 21, 2020. Therefore, you are responsible to pay a $200 copayment for days 1-2 (February 19, 2020 to February 20, 2020). The total amount you owe is: $200 (copayment) x 2 (inpatient days) = $400. You have been asked to pay the total copayment amount of $400 foran inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided from February 19, 2020 to February 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bariatric hospital bed (E0303).
You asked the Plan to pre-approve the bariatric hospital bed. You say that the heavy duty hospital bed is
medically necessary. The Plan denied your request. The Plan says coverage criteria is not met.
The Plan must follow Medicare rules. Medicare rules say that this type of hospital bed is covered when the
enrollee's weight exceeds 350 pounds.
We looked at the file and Medicare rules. The record does not show that the enrollee's weight exceeds 350
pounds. Based on this information, we decided that Medicare rules for coverage of the bariatric hospital bed
have not been met. Therefore, we decided that the Plan does not have to pre-approve a bariatric hospital bed
(E0303).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the infusion pump insertion provided from February 12, 2020 through February 13, 2020.
You asked the Plan to waive the coinsurance for the infusion pump insertion. You say that your previous surgeries did not cost this amount. You say that this will be difficult to pay. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for surgery performed at an in-network outpatient hospital facility. You have been asked to pay $2,932.25, which is 20% of the allowed amount for the infusion pump insertion. The allowed amount is $14,661.25 (20% x $14,661.25 = $2,932.25). The infusion pump insertion 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 the infusion pump insertion provided from February 12, 2020 through February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on August 21, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that the member gave you the wrong insurance information. The Plan denied your request. The Plan says 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 an office visit provided on August 21, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower overdenture (D5865).
You asked the Plan to pre-approve this service. You say that it is necessary that the denture be approved to fully complete the enrollee's treatment for better oral health. The Plan denied your request. The Plan says this service is not a covered benefit under the enrollee's contractual 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 requested service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete lower overdenture (D5865).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP battery backup. 
 
You asked the Plan to pre-approve a CPAP battery backup. You say that you have power outages and need a battery backup for your CPAP machine. The Plan denied your request. The Plan says power failures are not considered a medical problem. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Medicare will not pay for precautionary equipment. Therefore, we decided that the Plan does not have to pre-approve a CPAP battery backup.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on
December 21, 2019.
You asked the Plan to pay for the dental services. You say that before you went to have your teeth cleaned, you
assumed that they had checked with the plan and the receptionist said the insurance will take care of the bill.
The Plan denied your request. The Plan says this service exceeds the benefit frequency limitation.
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. This service is allowed once
every 2 years. Records show this service was provided May 3, 2018. Therefore, we decided that the Plan does
not have to pay for periodontal scaling and root planing (D4341) provided on December 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids you received on September 10, 2019.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says the benefit limit has been paid.
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 the Plan pays up to $500 for hearing aids every year. Review of the file shows that you were provided hearing aids on September 10, 2019. The records show that the plan has paid $500 toward the cost of the hearing aids. There is a $500 yearly benefit for hearing aids under your plan. 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 pay for the hearing aids you received on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 4, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is no valid referral for this 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 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 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on February 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you were not aware that you needed prior authorization. The Plan denied your request. The Plan says 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 an office visit provided on February 28, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the cost for the office visit provided on March 27, 2020.
You asked the Plan to waive the cost for the office visit. You say that you have never had a charge this high. You say that you cannot afford this. The Plan denied your request. The Plan says that the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan does not say in clear and accurate terms that you should expect to pay a $198 deductible. Your contract with the Plan says that enrollees pay a $0 copayment for provider and professional services at an in-network PCP's office or specialist's office.
The Plan says you must pay $71.04 toward the deductible for the office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the office visit. Therefore, we decided that the Plan has to waive the cost for the office visit provided on March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on January 10, 2020.
You asked the Plan to waive the copayment for the medical eye exam. You say that this was a routine eye exam and it was the same exam they have had for many years. 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 $45 copayment for each Medicare-covered outpatient visit for services to diagnose and/or a disease or condition of the eye. You have been asked to pay a $45 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The record shows diagnosis or age-related cataracts and glaucoma which makes the eye exam medical in nature.
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 medical eye exam provided on January 10, 2020.