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

We decided that the Plan does not have to waive the copayment forthe laboratory services received on July 20, 2020.You asked the Plan to waive the copayment forthe laboratory services. You say that you were not told that a laboratory copayment would apply.The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.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 laboratory tests. You have been asked to pay a $10 copayment for the laboratory services. The laboratory services fall within the outpatient diagnostic tests 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 forthe laboratory services received on July 20, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fororthotics (L0650, L1833, L2397) provided on August 12, 2020.You asked the Plan to pay fororthotics. You say that these items were medically necessary.The Plan denied your request. The Plan says there is not a valid proof of delivery for these items.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The itemized packing slip does not include the carrier's tracking number, and the proof of delivery is not itemized and does not include the address the items were delivered to. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay fororthotics (L0650, L1833, L2397) provided on August 12, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe emergency department services onDecember 30, 2019 and inpatient services provided from January 6-7, 2020.You asked the Plan to waive the copayments forthe emergency department service on December 30, 2019and inpatient services provided from January 6-7, 2020. You say that you should have no copayments.The Plan denied your request. The Plan says you have one copayment for one emergency department visit and one for an inpatient stay.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$90 copayment for emergency services and a $440 copayment for days 1-5 for Inpatient Services.You have been asked to pay a $440 copayment for days 1-5 for the inpatient services on January 6-7, 2020. The inpatient services fallwithin the Inpatient Servicesbenefit category. You have been asked to pay a $90 copayment for emergency services on December 30, 2019. 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 whenyou enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forthe emergency department services on December 30, 2019 and inpatient services provided from January 6-7, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the conformity evaluation (V5020) provided on August 24,
2020.
You asked the Plan to pay for the conformity evaluation. You say that you believe the Plan should cover this
service under their supplemental benefit. The Plan denied your request. The Plan says this service is not a
covered benefit.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file indicates that the services rendered were a routine hearing
aid check which are not covered under your Plan's supplemental hearing aid coverage. Based on this
information, we decided that the Plan's rules for coverage of the conformity evaluation have not been met.
Therefore, we decided that the Plan does not have to pay for the conformity evaluation (V5020) provided on
August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forwound debridement provided from January 2, 2020, through March 3, 2020.You asked the Plan to waive the copayment forwound debridement. You say that you were not aware that a follow up office visit was considered being in a hospital. You say that you don't have the funds to cover these bills.The Plan denied your request. The Plan says the claims reprocessed to only apply a $45 copayment for each visit.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductiblesand coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for physician specialist services. You have been asked to pay a $45 copayment for each wound debridement visit. The total amount you owe is $315 ($45/visit x 7 visits = $315). Wound debridement 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 forwound debridement provided from January 2, 2020, through March 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the
documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found the enrollee is noted to have osteoporosis. The documentation does not support that the enrollee
has tried and failed zoledronic acid. There is no documentation as to why zoledronic acid would not be
expected to be safe and effective for the enrollee. Therefore, the enrollee does not meet criteria for the
requested Prolia drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from April 16, 2020 to
July 9, 2020.
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 are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does
not have to pay for the home infusion therapy rendered from April 16, 2020 to July 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services were not urgent, emergent, 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 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 medical services provided on September 29, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plandoes not haveto pay forair ambulance services provided to the enrollee on June 22, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe receiving hospital was not the nearest hospital with appropriate facilities.The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services hospital to hospital only if the hospital to which the patient is transferred is the nearest one with appropriate facilities.The receiving hospital was not the closest hospital for the enrollee. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forair ambulance services provided to the enrollee on June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3320) provided on August 18,
2020.
You asked the Plan to pay for the endodontic therapy. You say that you cannot afford to pay for the dental
service. The Plan denied your request. The Plan says this service is not a covered benefit under your dental
plan.
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 the
endodontic therapy (D3320) provided on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physicians services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.
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 physician services provided on February 19, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for anintermediate intensive care unit (ICU) stay (0206) provided on May 15, 2020, through May 20, 2020.You asked the Plan to waive the copayment for anICU stay. You say that the services should be covered.The Plan denied your request. The Plan says the cost share was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment each day for days one to six for inpatient hospital care. You have been asked to pay a $295 copayment each day for days one to six for an ICU stay. This service 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 thePlan. 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 anintermediate intensive care unit (ICU) stay (0206) provided on May 15,2020, through May 20, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair scale and sales tax received on February 11,
2020.
You asked the Plan to pay for the wheelchair scale and sales tax. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the items received are not a covered
benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. The rules also say that Medicare pays for services only when they are furnished by a provider
or supplier enrolled in the Medicare program.
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. The wheelchair
scale was also provided by a provider that is not able to take Medicare payments. In addition, sales tax is not
reimbursable. Therefore, we decided that the Plan does not have to pay for the wheelchair scale and sales tax
received on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided on September 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the ophthalmology services. You say that you went to this provider because you had used them in the past when you had different insurance. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the ophthalmology services provided on September 10, 2020 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 crown (D2740) and core build up (D2950) for tooth # 30.
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says crowns are not listed as a covered service. The Plan says that core build up is not listed as a covered service either.
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 pre-approve a crown (D2740) and core build up (D2950) for tooth # 30.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided by an out-of-network (OON) provider.

You asked the Plan to pay for the outpatient services. You say that you disagree with this decision and request reconsideration of the denial of this claim.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 outpatient services provided on by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression garments identified with code S8424 and S8427.You asked the Plan to pre-approvethe compression garments. You say that you require these items for you lymphedema.The Plan denied your request. The Plan says that these items are non-covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that compression garments described by code S8424 and S8427 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression garments can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvecompression garments identified with code S8424 and S8427.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network provider.You asked the Plan to pre-approvethese services. You say that you will have permanent jaw damage if you aren't able to see this provider.The Plan denied your request. The Plan says the services are available from network providers.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.The Plan confirmed there are providers available that are qualified to treat your condition. 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-approvea referral to an out-of-network provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe diagnostic mammogram you had on September 17, 2020.You asked the Plan to waive the copayment forthe diagnostic mammogram. You say that you went in for a screening mammogram on September 4, 2020 but you had to return for another mammogram on September 17, 2020.  You say you shouldn't have to pay a copayment for the second mammogram.The Plan denied your request. The Plan says you were charged this copayment 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 $15 copayment for x-rays. Records show that you had a screening mammogram on September 4, 2020.  According to the medical records from that visit, you had a questionable nodule in the right outer breast that needed further evaluation with spot compression imaging.  You were asked to return on September 17, 2020 so that this nodule in the right breast could be further evaluated. This was not a second screening mammogram-this was a diagnostic mammogram of just the right breast.  You have been asked to pay a $15 copayment for the diagnostic mammogram. Because this was a diagnostic mammogram, it falls within the x-rays 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 forthe diagnostic mammogram you had on September 17, 2020.