Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve hearing aids to be provided by the requested out-of-network provider. You say that you need hearing aids to be able to hear. The Plan denied your request. The Plan says you must use the Plan's hearing aid provider to receive the 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. The Plan pays for hearing aids only when provided through the Plan's hearing aid network provider. We looked at the file and the Plan's rules. The file shows that the provider you requested is not part of the Plan's hearing aid provider network. Therefore, we decided that the Plan does not have to pre-approve hearing aids to be provided by the requested out-of-network provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services provided from June 10, 2021, to June 16, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that the enrollee was released from the facility and then admitted to a new SNF, so the 20 fully-covered days should have restarted. The Plan denied your request. The Plan says the enrollee was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment per day for days 1-20, and a $184 copayment per day for days 21-43 for skilled
nursing facility services. Records show that the enrollee was in the SNF from May 7, 2021, to May 28, 2021, for a total of 21 days. She was discharged and then admitted to another SNF from June 10, 2021, to June 16, for a total of 6 days. The enrollee has been asked to pay a $184 copayment per day for each of the 6 days from June 10, 2021, to June 16, 2021. According to the Evidence of Coverage, the SNF cost sharing applies to each benefit period. A benefit period does not restart unless the enrollee has not been in any hospital or SNF for 60 days. That was not the case here. The enrollee was readmitted to a SNF within two weeks of her previous admission, so the second SNF stay is considered part of the same benefit period for purposes of cost sharing calculation. 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 skilled nursing facility (SNF) services provided from June 10, 2021, to June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lab services you received on July 20, 2021.
You asked the Plan to waive the deductible for the lab services. You say that you were never alerted to the Plan change that you now have a deductible. The Plan denied your request. The Plan says you were assessed this amount towards your deductible correctly.
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 a $250 deductible which applies to lab services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible which applies to lab services. This cost sharing is a contractual obligation that had not been met at the time the lab services were received on July 20, 2021. Therefore, we decided that the Plan does not have to waive the deductible for lab services you received on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the outpatient nuclear medicine services
you received on November 30, 2020 and May 11, 2021.
You asked the Plan to reduce the copayments for the outpatient nuclear medicine services. You say that the
Plan will not assume responsibility for misinformation their representatives are giving consumers. You say that
you called the Plan to request pricing for tests that your cardiologist recommended and that the Plan
representative told you your copayment would be $20. You say that several months later you received an
invoice from the provider for $220 for the initial tests and another invoice for $110 for the additional test. You
say that after some time, the provider reimbursed you the initial $220 you paid and canceled the $110 invoice.
The Plan denied your request. The Plan says you received outpatient testing on the dates of service at issue in
this appeal. The Plan says the correct copayments have applied per your contract with the Plan.
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 $110
copayment for Outpatient diagnostic tests.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you had outpatient diagnostic
tests provided in an outpatient hospital setting on November 30, 2020 and May 11, 2021. You have been asked
to pay a $110 copayment for each test. The outpatient nuclear medicine 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 reduce the copayments for the outpatient nuclear
medicine services you received on November 30, 2020 and May 11, 2021.
Your complaint about the Plan not assuming responsibility for providing consumers with incorrect information
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network mental health care provided from May 26, 2021, to July 21, 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 did not have prior authorization for 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 must 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 out of network mental health care provided from May 26, 2021, to July 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on February 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. 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 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 physician services provided on February 1, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs (ibuprofen) provided during an
outpatient procedure on October 7, 2020.
You asked the Plan to pay for self-administered drugs under Medicare Part B. You say that this bill should be
covered by the Plan. The Plan denied your request. The Plan says self-administered drugs are not covered
under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs
(ibuprofen) provided during an outpatient procedure on October 7, 2020.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room (ER) visit you had on
June 9, 2021, and the inpatient hospital services provided from June 9, 2021, to June 12, 2021.
You asked the Plan to waive the copayments for the ER visit and the inpatient hospital services. You say that
all you did was lay in bed for two days. You think these copayments are outrageous and you cannot afford it.
The Plan denied your request. The Plan says you were charged these copayments 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 emergency room visits and a $210 copayment per day for days 1-6 for inpatient hospital care.
You have been asked to pay a $90 copayment for the ER visit and a $210 copayment per day for the inpatient
hospital services. Records show you were in the hospital for three days, so your inpatient hospital copayment
totals $630. This means that you have been asked to pay the correct amounts 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 emergency room (ER) visit you had on
June 9, 2021, and the inpatient hospital services provided from June 9, 2021, to June 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient psychiatric admission.
You asked the Plan to pre-approve the inpatient psychiatric admission. You say that inpatient mental health treatment would be beneficial for this enrollee. The Plan denied your request. The Plan says the service is not covered because the records indicate that the enrollee is a prisoner or in custody of a Federal, State, or local authority.
The Plan must follow Medicare rules. Medicare rules say that the Medicare program does not pay for services if the beneficiary has no legal obligation to pay for the services and no other person or organization has a legal obligation to provide or pay for that service.
We looked at the file and Medicare rules. The records show that the enrollee was incarcerated at the time of this request. Based on this information, we decided that Medicare rules for coverage of the inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient psychiatric admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the application of a paste boot provided
from July 2, 2021, to July 16, 2021.
You asked the Plan to reduce the copayment for the application of a paste boot. You say that you thought you
only had a $40 copay for each visit. You say you cannot afford the copays. 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 $350
copayment for each surgery at an outpatient hospital facility.
The service you received is considered a surgical service. You have been asked to pay $166.87, which is less
than the $350 copayment for each application of a paste boot. The application of a paste boot 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 reduce the copayment for the application of a paste
boot provided from July 2, 2021, to July 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy (PT) services you received from May 7, 2021, to July 27, 2021/
You asked the Plan to waive the copayments for the PT services. You say that you were told there would be no charge for these services The Plan denied your request. The Plan says you were charged these copayments 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 $40 copayment per day for physical therapy services. You have been asked to pay a $40 copayment per day for the PT services. 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 physical therapy (PT) services you received from May 7, 2021, to July 27, 2021/
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (85379, 93971) provided from July 14, 2021, to July 15, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that you were not aware that prior authorization was needed. The Plan denied your request. The Plan says you are not a network provider with the Plan. The Plan also says that the services were not referred by a network provider or rendered in an in-network facility, the services were not urgent or emergent, and the services were not approved in advanced.
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 Plan contract also says that you must obtain authorization from the plan prior to seeking care from an out-of-network provider.
The requested 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 laboratory services (85379, 93971) provided from July 14, 2021, to July 15, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that your physician prescribed incontinence supplies is needed from a bad surgery. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 2, 2021.
You asked the Plan to pay for the laboratory 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 are not supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve photodynamic therapy (PDT) visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve photodynamic therapy visits. You say that the Plan does not provide the photodynamic therapy that you require. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network provider.
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 photodynamic therapy (PDT) visits to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you have a lower back problem and cannot bent down. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on May
19, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for 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 must 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 out of network lab services provided to the
enrollee on May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on July 13, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care and the ordering physician also is not a Plan contract provider.
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 out of network medical services provided to the enrollee on July 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment ordered both online out of network on June 21, 2021.
In your appeal to the Plan and in a letter sent directly to Maximus, you stated that you were told this equipment was approved and cannot afford to pay this bill. The Plan denied your request. The Plan says the prescription for the durable medical equipment was sent to a Plan contract provider. However, you chose to purchase this equipment from a non-Medicare participating store, rather than a Medicare approved durable medical equipment supplier. You have prior authorization for this equipment but not this provider.
Medicare rules say that plans can require enrollees to get care from network providers. Medicare cannot pay for equipment obtained from providers who are not Medicare eligible vendors. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider you purchased this equipment from was both out of network and was not a Medicare eligible provider. You did not follow your Plan contract agreement when you purchased this equipment. 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 durable medical equipment ordered both online out of network on June 21, 2021.