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

We decided that the Plan does not have to waive the copayment for the observation stay provided on September 25, 2019.
You asked the Plan to waive the copayment for the observation stay. You say that you were informed you were not admitted. You say that you were advised you would only be billed for the emergency room. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment per service. If emergency room and observation facility are billed on same day, the observation copayment will be taken. You have been asked to pay a $275 copayment for the observation stay. The observation stay falls within the "Outpatient hospital services" benefit category. The records show that you were admitted for outpatient observation. 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 observation stay provided on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
September 20, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not have to
pay a copayment to schedule a preventative procedure. 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 $40
copayment for services obtained from an in-network specialist or under certain circumstances, treatment by a
nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's
office.
You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner Services, Including Doctor's Office Visit" benefit category. The record
shows the specialist office visit is not considered a part of the preventative procedure.
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 specialist office visit provided on September 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 9, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 to the enrollee by an out-of-network provider on October 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periapical x-ray (D0220), and the resin based composite, 2 surfaces, for an anterior tooth (D2331) provided on October 22, 2019.You asked the Plan to pay forthe dental services. You say that you received emergency dental services. You say that you were experiencing a lot of pain and were unable to sleep because of it.The Plan denied your request. The Plan says periapical x-rays and fillings are not covered services.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 dental services you recieved are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe periapical x-ray (D0220), and the resin based composite, 2 surfaces, for an anterior tooth (D2331) provided on October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement frames (V2020) and lenses (V2100).
You asked the Plan to pre-approve eyeglasses replacement. You say that you sat on your glasses 2 months ago and broke them. Your lenses are covered under warranty but not the frames and you need them both. The Plan denied your request. The Plan says this request exceeds the benefit limit of once a year.
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 1 pair of eyeglasses (frames and lenses) or contact lenses every year. There is a $200 limited eyewear benefit. Records show that you received an eye exam and glasses in June 2019. We looked at the file and the Plan's rules. The provider where the original eyeglasses was purchased from will replace the lenses under warranty but not the frames. The eyewear benefit is not available until June 2020. Based on this information, we decided that the Plan's rules for coverage of eyeglasses replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement frames (V2020) and lenses (V2100).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on March 19, 2019 and billed under codes 80307 and G0483.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says that Current Procedural Terminology (CPT) codes 80307 and G0483 remain not supported. The place of service (POS) on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The claim indicates the specimen was obtained in a laboratory or POS 81; however, the medical records indicate the specimen was obtained in an office setting or POS 11. Also, the laboratory results submitted indicate the specimen was collected on March 19, 2019 and received by the lab on March 25, 2019. Therefore, the billed coded cannot be verified. In addition, the documentation does not indicate the method of testing utilized to support the billed code. The Plan notes multiple attempts were made to obtain additional information from the provider.
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. Medicare requires the correct place of service code be documented on the claim. In addition, the physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes.
Based on the records provided, the claim submitted has errors that prevent payment. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on March 19, 2019 and billed under codes 80307 and G0483.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for an emotional and behavioral assessment (96127) provided on August 12, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an emotional and behavioral assessment. You say that you are requesting a review of medical documentation for medical necessity and reconsideration of denied services. The Plan denied your request. The Plan says the Provider is a non-contracted provider. The enrollee's plan requires her to receive care from in-network providers. There was no valid referral on file for the service in question. In addition, the enrollee's services were not urgent or emergent in nature. The Health Plan does not deny the medical necessity. There was no authorization for 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 an emotional and behavioral assessment (96127) provided on August 12, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Ultra Blue test strips.You asked the Plan to pre-approvethe non-preferred brand of test strips. You say that the enrollee has usedthe One Touch Ultra Blue test stripssince 2014.The Plan denied your request. The Plan saysthey will approve a 3 month transition supply with no refills because there is no documentation of medical necessity of this brand.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 is no documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met.Therefore, we decided that the Plan does not have to pre-approveOne Touch Ultra Blue test strips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the nivolumab injection provided on December 11, 2019.
You asked the Plan to waive the coinsurance for the nivolumab injection. You say that you had been getting treatments without being charged. You say that you believe this is a mistake and you should not be charged. 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% of the cost for Part B covered chemotherapy drugs and other Part B covered drugs. You have been asked to $61.13, which is less than the standard 20% coinsurance for the nivolumab injection because you met your maximum out-of-pocket. The nivolumab 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 nivolumab injection provided on December 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystourethroscopy provided on October 14, 2019.You asked the Plan to waive the copayment for the cystourethroscopy. You say that the procedure is not a surgery, it is a scope done at the clinic. 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 $400 copayment for Medicare-covered services received in an in-network outpatient hospital facility. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $400 copayment for cystourethroscopy.You have been asked to pay a $399copayment for the cystourethroscopy. The cystourethroscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the cystourethroscopy is considered a surgical procedure.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 cystourethroscopy provided on October 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Novolog.You asked the Plan to pre-approve the tier exception. You say that you need the tier exception for the Novolog.The Plan denied your request. The Plan says tier exceptions are not available for Novolog.The Plan must follow Medicare rules. Medicare rules say that Tier exceptions only apply to drugs covered under Medicare Part D. We looked at the file and Medicare rules. The Novolog here is used in conjunction with an Insulin Pump. In this case, the Novolog is covered under the Part B medical benefit and does not qualify for a tier exception. Based on this information, we decided that Medicare rules for coverage of the tier exception have not been met.Therefore, we decided that the Plan does not have to pre-approve a tier exception for Novolog
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on October 10, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that you went back to the ED to have staples removed. You say that there shouldn't be a copayment for a follow up visit. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. There is no provision in the contract which indicates an ED copayment would be waived if performed as a follow-up 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. Therefore, we decided that the Plan does not have to waive the copayment for the ED visit provided on October 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the pontic (D6240) for tooth # 10 provided on September 23, 2019.You asked the Plan to pay the in network rate for the pontic. You say that when you joined the plan, you requested an in network dentist. You say that you were given the number for the provider by a plan representative. You also say that the dental office confirmed they were in network.The Plan denied your request. The Plan says the pontic is not listed as 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, the pontic is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay the in network rate for the pontic (D6240) for tooth # 10 provided on September 23, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the chemotherapy administration or the denosumab injection provided on July 8, 2019.
You asked the Plan to reduce the coinsurance for the chemotherapy administration and the denosumab injection. You say that you believe this bill should be $110.54. You say you paid the smaller amount in the past. 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 20% coinsurance for chemotherapy drugs at an in-network outpatient hospital. You have been asked to pay a total of $354.33 for the chemotherapy administration and the denosumab injection. The chemotherapy administration and the denosumab injection fall within the "Medicare Part B prescription drugs" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
July 8, 2019
Chemo administration
$53.60
20%
$10.72
July 8, 2019
Denosumab injection
$1,718.06
20%
$343.61
Total
$354.33
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 reduce the coinsurance for the chemotherapy administration or the denosumab injection provided on July 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve post and core in addition to crown, indirectly fabricated, (D2952).
You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says post and core in addition to crown, indirectly fabricated, is not listed as 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, post and core in addition to crown, indirectly fabricated, is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve post and core in addition to crown, indirectly fabricated, (D2952).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam provided on August 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an eye exam. You say that you do not understand why this was denied. The Plan denied your request. The Plan says these services can be provided in-network. The Plan says that no prior authorization was obtained for 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 an eye exam provided on August 26, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the implant supported crown on a posterior tooth (D6065) for tooth # 14 provided on November 18, 2019.
You asked the Plan to reimburse you for the dental service. You say that you were advised by 2 different dentists that you need an implant. You say that it has taken you awhile to save money to have this service done. You also say that you do not understand the difference between a crown and an implant supported crown. The Plan denied your request. The Plan says implant supported crown on a posterior tooth is not a covered service. The Plan also says that implant supported crowns are limited to anterior teeth.
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 implant supported crown for a posterior tooth is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the implant supported crown on a posterior tooth (D6065) for tooth # 14 provided on November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea total electric hospital bed.You asked the Plan to pre-approvea total electric hospital bed. You say that your doctor says you need a hospital bed to use with your lift.The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvea total electric hospital bed.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) provided on September 18, 2019.
You asked the Plan to pay for the physician service. You say that the enrollee was not enrolled in hospice at the time the services were provided to them. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage enrollee on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) provided on September 18, 2019.