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

We decided that the Plan does not have to waive the coinsurance for the Medicare Part B prescription drugs
provided on March 3, 2021, through March 24, 2021.

You asked the Plan to waive the coinsurance for the Medicare Part B prescription drugs. You say that you
would like reconsideration because you believe you have met your out-of-pocket maximum and these charges
could affect your grant and prevent you from receiving future treatment. The Plan denied your request. The
Plan says the cost share amount has been 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 20%
coinsurance for Outpatient Hospital Services.

You have been asked to pay a 20% coinsurance for the Medicare Part B prescription drugs. These drugs fall
within the Outpatient Hospital Services 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. Please note, the record indicates that you have been asked to pay the full
amount for the self-administered drugs on this claim. These services are recorded with revenue code 637 on
your explanation of benefits. Medicare Part B does not pay for self-administered drugs. Additionally, the
record indicates that you had not reached your out-of-pocket maximum as of the date of appeal. Therefore, we
decided that the Plan does not have to waive the coinsurance for the Medicare Part B prescription drugs
provided on March 3, 2021, through March 24, 2021.

Benefits for the 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing (CPT code(s): 81286, 81404, 81407, 81408, 81479) provided to the enrollee on November 25, 2020.

You asked the Plan to pay for the genetic testing. You say that the claim should be paid. The Plan denied your request. The Plan says they did confirm with the provider and they denied the order for genetic testing.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. The rules say that laboratory tests must be ordered by the physician or NPP who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Test not ordered by the physician or NPP who is treating the beneficiary are not reasonable and necessary. The Plan states they did confirm with the enrollee's doctor that they did not order the genetic testing. Therefore, we decided that the Plan does not have to pay for the genetic testing (CPT code(s): 81286, 81404, 81407, 81408, 81479) provided to the enrollee on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on February 19, 2021.

You asked the Plan to waive the copayment for these services. You say that you are dissatisfied with the services. The Plan denied your request. The Plan says the copayment 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 $45 copayment for each Medicare-covered specialist visit.

Review of the file shows that you received specialist services on February 19, 2021. Per the contract with the Plan, there is a $45 copayment for each Medicare-covered specialist visit. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $36.43. Given that the allowed amount was less than the $45 copayment you have been asked to pay $36.43 for these services. Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on February 19, 2021.

Your complaint about the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine care as part of a clinical trial for the enrollee's cancer.

You asked the Plan to pre-approve the services. You say that the services should be covered. The Plan denied your request. The Plan says once a member signs a Medicare approved clinical trial consent form, Original Medicare is responsible for covered clinical trial services furnished to beneficiaries enrolled in managed care plans.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, once a member signs a Medicare approved clinical trial consent form, Original Medicare is responsible for covered clinical trial services furnished to beneficiaries enrolled in managed care plans. Therefore, we decided that the Plan does not have to pre-approve routine care as part of a clinical trial for the enrollee's cancer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the two complete dentures - mandibular (D5120) provided July 22, 2021, by an out-of-network (OON) provider.  You asked the Plan to provide additional payment for the two complete dentures. You say that you were unaware the dentures provided would not be covered 100% and would have gone to a different provider had you been informed. The Plan denied your request. The Plan says you are responsible for the difference between the Plan's allowed amount and the total cost billed by an OON provider. You were billed for two lower dentures on this date of service, and the second set is not covered.  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 the two complete dentures once every five years.  For services provided OON, you may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider.  We looked at the file and Medicare rules. In this case the Plan provided documentation showing that they covered 100% of the allowed amount for one complete lower denture. You are responsible for the difference between the allowed amount paid by the Plan and the total cost billed by the OON provider. The second set of complete lower dentures billed by the provider on July 22, 2021, is not covered because it exceeds the Plan's frequency limit for this service. Therefore, we decided that the Plan does not have to provide additional payment for the two complete dentures - mandibular (D5120) provided July 22, 2021, by an out-of-network (OON) provider.   Your complaint about potentially receiving misinformation from a Plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the evaluation and management services provided on June 18, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the OON services. You say that the services were medically necessary for this enrollee. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.   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 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 evaluation and management services provided on June 18, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health care provided in patient's home/residence and direct skilled nursing services of a registered nurse (RN) provided from January 1, 2021, to January 28, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the home health care and skilled nursing services. You say that you provide all of the home care services the enrollee needs. The Plan denied your request. The Plan says the treating provider is not a network provider. The Plan also says that these services were not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 home health care provided in patient's home/residence and direct skilled nursing services of a registered nurse (RN) provided from January 1, 2021, to January 28, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory work provided on August 10, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory work. You say that the enrollee did not come to the lab which means they did not use their out-of-network benefits. You say the participating doctor sent the specimen. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on August 10, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the routine vision services provided on June 30, 2021.  You asked the Plan to pay for the routine vision services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not a participating provider under your routine vision benefit.  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 routine vision care when provided by a participating provider.  We looked at the file and the Plan's rules. In this case, the file shows that you received routine vision services with a non-participating provider under your routine vision care benefit. Based on this information, we decided that the Plan's rules for coverage of the routine vision services have not been met. Therefore, we decided that the Plan does not have to pay for the routine vision services provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a urology consultation to be provided by an out-ofnetwork
provider.
You asked the Plan to pre-approve urology visit. You say that this provider is part of your medical group, came
highly recommended, and is in much closer proximity to your home than other urologists. The Plan denied
your request. The Plan says the denial of authorization for this service is correct, because this provider is outof-
network with the Plan and you can be treated by an in-network urologist.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is
considered accessible to an enrollee if contract providers are available within reasonable distance and travel
time from the enrollee's home. The Plan says that enrollees must use contract providers.
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located
within reasonable distance and travel time from your home who can provide urology visit. Under Medicare
rules, this means that contract providers are accessible to you. Therefore, we decided that the Plan does not
have to pre-approve a urology consultation to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an automatic external defibrillator (K0606), provided on May 8, 2021 to June 8, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for an automatic external defibrillator. You say that the item was medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services obtained through an out-of-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 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 an automatic external defibrillator (K0606), provided on May 8, 2021 to June 8, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids (CPT code(s): V5261 and V5010) purchased on January 15, 2021, from an out-of-network provider.  You asked the Plan to pay for the hearing aids. You say that you are requesting the Plan reconsider and apply additional benefit. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC 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).   As per your EOC page 91 you have to pay 25% coinsurance, then any amount over $1,000 every 3 years for the out-of-network provider. The Plan reimbursed you $1,000 on October 20, 2021, and also Hear USA reimbursed you $1,000 on October 20, 2021. Since, you have reached the limit the Plan is not able to reprocess and pay the claims. You will be responsible for the payment. Therefore, no changes can be made to your claims. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for the hearing aids (CPT code(s): V5261 and V5010) purchased on January 15, 2021, from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the hand splints provided on April 28, 2021.

You asked the Plan to waive the coinsurance for the hand splints. You say that you were not told you would have to pay $194.18 for the splints. You say you were led to believe the splints were covered. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.

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 enrollees must pay a $0 copayment for Medicare-covered prosthetic devices and related supplies. 

The Plan says you must pay a $113.07 coinsurance for the hand splints. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the hand splints. The record shows the hand splints are considered a type of brace. Therefore, we decided that the Plan has to waive the coinsurance for the hand splints provided on April 28, 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a computed tomography scan (70450) provided on October 8, 2021.  You asked the Plan to pay for a computed tomography scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography scan (70450) provided on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supplies provided on July 13, 2021.  You asked the Plan to pay for the services provided. You say that the items were provided at your own cost. The Plan denied your request. The Plan says the codes are not valid for Medicare purposes.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.     We looked at the file and the rules. We find that CPT code S1015 and S8301 is not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the supplies provided on July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing services provided on September 22, 2021, by an out-of-network provider.  You asked the Plan to pay for the out-of-network services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.  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 genetic testing services provided on September 22, 2021, by an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit provided on June 23, 2021.  You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $90 copayment for each emergency care visit.    You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit provided on June 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for diabetic shoes purchased on June 6, 2019.  You asked the Plan to waive the coinsurance for diabetic shoes. You say that the item 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 20% coinsurance for diabetes self-management training, diabetic services and supplies.   You have been asked to pay a 20% coinsurance for diabetic shoes. This item falls within the diabetes self-management training, diabetic services and supplies 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 diabetic shoes purchased on June 6, 2019.