Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on June 23, 2021.
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says an eye refraction is not a covered benefit since it was a medical vision check performed (Type 2 diabetes). Eye refractions are only covered by the plan if performed by a participating vision provider and performed as a routine screening.
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file and Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on June 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on April 9 to June 21, 2021.
You asked the Plan to pay for psychotherapy services. You say that the provider at issue specializes in anxiety disorders and was highly recommended. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on April 9 to June 21, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services (99283) rendered 
on May 20, 2021. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you went to the 
emergency room earlier for a nosebleed and paid a copayment. You also say that you returned the same day to 
the same emergency room for another nosebleed and was told no copayment would be billed. The Plan denied 
your request. The Plan says you were 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 $50 
copayment for each Medicare-covered emergency room visit. 
 
You have been asked to pay a $50 copayment for emergency room services (99283). The record shows that you 
were not immediately admitted to the hospital. 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 emergency 
room services (99283) rendered on May 20, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the complete electrocardiogram (ECG) (93000) and complete ultrasound of aorta (93978) provided on April 8, 2021.
You asked the Plan to waive the copayments for the ECG and ultrasound. You say that these services were provided as part of your annual wellness visit, and it was implied that they were covered as part of this service without extra cost. The Plan denied your request. The Plan says these services are covered, and the copayments were assessed in accordance with your contract. Lab tests, radiological diagnostic tests and non-radiological diagnostic tests are not included as part of the annual wellness visit.
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 $155 copayment for each Medicare-covered radiological diagnostic service and a $30 copayment for each Medicare-covered non-radiological diagnostic service. An annual wellness visit does not include lab tests, radiological diagnostic tests or non-radiological diagnostic tests. Additional cost share may apply to any lab or diagnostic testing performed during your visit, as described for each separate service in this Medical Benefits Chart. You have been asked to pay a $155 copayment for the ultrasound and a $14.96 copayment for the ECG. The ultrasound is a Medicare-covered radiological diagnostic service, and the ECG is a non-radiological diagnostic service. 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 copayments for the complete electrocardiogram (ECG) (93000) and complete ultrasound of aorta (93978) provided on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve maxillary partial denture - cast metal framework 
(D5213). 
 
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your 
request. The Plan says the five year time frame has not elapsed. 
 
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. The Plan covers dentures once 
every five years. 
 
Dentures were last received less than five years ago on May 29, 2020. Based on this information, we decided 
that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does 
not have to pre-approve maxillary partial denture - cast metal framework (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the system. You say that the current power wheelchair is over five years old 
and in poor repair. The Plan denied your request. The Plan says this is 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 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. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on October 23, 2020.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says we cannot confirm Medicare coverage has been met.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on October 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the duplex scan and the Vitamin B-12 
injection you received on April 8, 2021. 
 
You asked the Plan to waive the cost sharing for the duplex scan and the Vitamin B-12 injection. You say that 
you visited your primary doctor for the first time and you were told these tests fall under the annual 
wellness/physical exam benefit.  As a result, it was implied that you would not be charged for these services. 
The Plan denied your request. The Plan says you were charged this cost sharing 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 $155 
copayment for radiological diagnostic services and 20% coinsurance for Medicare Part B drugs.  
 
You have been asked to pay a $155 copayment for the duplex scan and 20% coinsurance for the Vitamin B-12 
injection. The duplex scan falls within the radiological diagnostic services benefit category. The Vitamin B-12 
injection falls within the Medicare Part B drug benefit category.  Your Evidence of Coverage explicitly states 
that testing and other services received during an annual wellness visit or a physical exam are not included, and 
separate cost sharing will apply. 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 sharing for the duplex scan and the 
Vitamin B-12 injection you received on April 8, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services (99283) rendered 
on July 24, 2021. 
 
You asked the Plan to waive the copayment for emergency room services. You say that due to the delay in 
wound care, you were exposed to bugs. You also say that you were sent to the emergency room as a result The 
Plan denied your request. The Plan says you were 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 Emergency Care.  
 
You have been asked to pay a $120 copayment for emergency room services (99283). 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 emergency room services (99283) rendered on July 24, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of the abdomen (76700) 
provided on July 30, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that this was a preventative ultrasound 
and should be covered with no copayment. The Plan denied your request. The Plan says this claim was 
processed correctly, and your copayment was assessed in accordance with your contract. 
 
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 $50 
copayment for diagnostic procedures and tests, including ultrasounds.  

You have been asked to pay a $50 copayment for the ultrasound. 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 ultrasound of the abdomen (76700) provided on July 30, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient admission and services provided from March 23, 2021, to April 3, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that the enrollee was in the same facility since March 11, 2021, and they are being double billed for the same hospital stay. They were moved back to the rehab on March 23, 2021, after the weekend, but were never discharged from the facility. The Plan denied your request. The Plan says this claim was processed correctly, and the enrollee's copayment was assessed in accordance with the contract.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for each of the first seven days of an inpatient hospital admission. There is a
$1,750 maximum copayment per admission. A cost-sharing is charged for each inpatient stay. The enrollee has been asked to pay a $1,750 copayment for the inpatient admission which exceeded seven days and began on March 23, 2021. Documentation shows that the enrollee was admitted to a different level of care on March 23, 2021. Even though this transfer was within the same facility, admission to a different level of care is generally considered a new inpatient admission. The Plan applies cost-sharing for each inpatient stay. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient admission and services provided from March 23, 2021, to April 3, 2021.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment for the emergency room visit provided on April 9, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly to the service provided.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not provided medical records to our organization to review and determine if you were admitted into the hospital within twenty four hours of your emergency visit for the same condition. Therefore, we decided that the Plan has to waive the copayment for the emergency room visit provided on April 9, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a group 2 heavy-duty power wheelchair. 
 
You asked the Plan to pre-approve a group 2 heavy-duty power wheelchair. You say that your current 
wheelchair is over 10 years old, and it affects your wellbeing not having a wheelchair. The Plan denied your 
request. The Plan says that that records show you have an existing wheelchair provided in 2020. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided documentation confirming you were issued a new 
power wheelchair within the last five years. The information provided indicates a wheelchair was approved in 
2020, but does not indicate you were delivered/received a new power wheelchair. Therefore, we decided that 
the Plan has to pre-approve a group 2 heavy-duty power wheelchair.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 12, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on November 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 29, 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 procedure code 88432 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 88342 (immunohistochemistry antibody slide, first stain) and 88344 (immmunohistochemistry, per specimen). Code 88342 is a column II code with a modifier indicator of 1 when billed with column I code 88344. Code 88342 was not billed with an appropriate modifier to allow
for separate payment. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 12, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you were insured primarily by another Plan until November 30th, 2020, at which time you took a temporary job that included medical insurance. This made your current Plan your secondary insurance. On May 1st, 2021, the current Plan again became the primary insurance. While multiple claims were adjusted to reflect the order of coordination of benefits, some providers have not yet filed primary insurance claims, so the Plan is unable to process as secondary payer until the primary claims have been received. Multiple attempts have been made to obtain explanations of payments for the months that this Plan was the secondary payer. Without the primary explanation of payment from the primary payer at the time of service, these claims cannot be reviewed for further payment.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the primary payor at the time of service and requested the claims history. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for physician services provided on April 12, 2021
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on
June 25, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you had a colonoscopy that morning
and were advised if your temperature spiked over 101 degrees to go to the ER. You stated that your
temperature spiked to 101.5, which is why you went to the ER. You believe that this copayment should be
waived because this ER visit was on the same day as the colonoscopy. 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 $75
copayment for emergency room visits.
You have been asked to pay a $75 copayment for the ER visit. This copayment applies regardless of the reason
for the ER 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 emergency room (ER) visit
you had on June 25, 2021.