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

We decided that the Plan does not have to pay for the chiropractic services provided on April 29, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the chiropractic services. You say that you were never told that you had to use an in-network provider. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on April 29, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility services you received from April 5, 2021, to April 29, 2021.

You asked the Plan to waive the copayment for the skilled nursing facility services. You say that the facility told you that there was no charge for these services. 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 $0 copayment per day for days 1-20 and a $172 copayment per day for days 21-100 for skilled nursing facility services.

Records show that you were in the nursing facility for 24 days. You were charged $0 for the first 20 days. You have been asked to pay a $172 per day copayment for the remaining 4 days, for a total of $688. 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 skilled nursing facility services you received from April 5, 2021, to April 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the finger fracture repair surgery you had at an outpatient hospital facility on March 23, 2021.

You asked the Plan to reduce the copayment for the outpatient surgery. You say that you had this surgery at a surgery center, not a hospital facility. The Plan denied your request. The Plan says although the health center where you received services provides outpatient surgery at one of their affiliated locations, the actual facility where you had this surgery is not a freestanding ambulatory surgery center. The hospital bills for these services at outpatient hospital services.

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 $175 copayment for outpatient surgery at an outpatient hospital facility.

You have been asked to pay a $175 copayment for the outpatient surgery. We confirmed in your online Plan Directory that the facility where you had these services is not considered an ambulatory surgery center, but rather an outpatient hospital facility. 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 finger fracture repair surgery you had at an outpatient hospital facility on March 23, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on August 8, 2020.

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 this claim must be submitted to Original Medicare first for review.

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 medical services provided to the enrollee on August 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the wound debridement procedures you had from May 7, 2021, to May 24, 2021, at an outpatient hospital facility.

You asked the Plan to waive the copayments for the wound debridement procedures. You say that you do not feel as though you should have a copayment because these wound care services were to remove plastic staples used during breast surgery. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that because the allowed amount for each date of service are less than your copayment obligation, you are responsible for the full allowed 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 $200 copayment for outpatient hospital services.

You have been asked to pay a $200 copayment for the wound debridement procedures. The wound debridement procedures 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. Therefore, we decided that the Plan does not have to waive the copayments for the wound debridement procedures you had from May 7, 2021, to May 24, 2021, at an outpatient hospital facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463) provided on May 25, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a hospital outpatient clinic visit. You say that the patient was seen for tongue concerns and a bad taste in the mouth. You also say you would like reconsideration for payment. The Plan denied your request. The Plan says services should be received from network providers who are listed in the provider directory, except when urgent or an emergency.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a hospital outpatient clinic visit (G0463) provided on May 25, 2021, by an out-of-network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy (PT) visits you had from March 18, 2021, to April 22, 2021.

You asked the Plan to waive the copayments for the PT visits. You say that the PT office told you that you would only have to pay $35 for six sessions. You said that were not properly informed of the cost sharing. The Plan denied your request. The Plan says you were charged these copayments correctly. In addition, the Plan says that your copayment is $40 per session, not $35.

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 physical therapy services. 

Records show that you had 5 PT visits. You have been asked to pay a $40 copayment for each of the 5 visits.

This copayment is a per-service copayment, which is why five copayments of $40 have been charged. Since you already paid $35, you have a remaining balance of $165. 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 physical therapy (PT) visits you had from March 18, 2021, to April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve your OTC benefit allowance for quarters one and two of 2021 to be carried over to your third quarter benefits.

You asked the Plan to pre-approve your OTC benefit allowance for quarters one and two of 2021 to be carried over to your third quarter benefits. You say that you requested the OTC catalog twice in the past and you did not receive it until after the start of the third quarter of 2021. You say that you should have the first and second quarter put on to your third quarter benefits in the amount of $150.00. The Plan denied your request. The Plan says quarterly allowances cannot be carried over to another quarter.

The Plan contract covers an Over-the-Counter Drug Allowance. Orders are limited to one per quarter. Quarterly allowances cannot be carried over to another quarter. 

We looked at the file and the Plan's rules. The file shows that the OTC benefit says that quarterly allowances cannot be carried over to another quarter. Therefore, we decided that the Plan does not have to pre-approve your OTC benefit allowance for quarters one and two of 2021 to be carried over to your third quarter benefits.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on January 29, 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 this claim must be submitted to Original Medicare first.

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 medical services provided to the enrollee on January 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig (A9282).
You asked the Plan to pre-approve the wig. You say that the wig is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig (A9282).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care services provided on May 13, 2021.

You asked the Plan to waive the copayment for wound care services. You say that you disagree with the charges because none of this was your fault and you should not have to suffer further from this ordeal. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $200 copayment for outpatient hospital services. 

You received wound care services at an outpatient hospital facility on May 13, 2021. Therefore, you are responsible to pay the allowed amount of $110.51, which is less than the $200 copayment. 

You have been asked to pay $110.51 for wound care services. Wound care services 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. Therefore, we decided that the Plan does not have to waive the copayment for wound care services provided on May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on May 12, 2021.

You asked the Plan to waive the copayment for laboratory services. You say that you never had to pay for laboratory services in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $30 copayment for laboratory services.

 You have been asked to pay the allowed amount of $21.57, which is less than the $30 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic 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 copayment for laboratory services provided on May 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97530) provided November 12, 2019.

You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 97530 is not supported in the medical record. Specifically, the record shows the services were provided by a therapy assistant. There is a more appropriate CPT code to describe the services when provided by a therapy assistant (G0158). Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97530) provided November 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography (93458) provided on May 14, 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 the copayment has been applied correctly to the service provided.

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 $225 copayment for each Medicare-covered outpatient hospital facility visit.

You have been asked to pay a $225 copayment for the outpatient surgery provided. 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 catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography (93458) provided on May 14, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on January 20, 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 this claim must be submitted to Original Medicare first for review.
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 medical services provided to the enrollee on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on May 17, 2021.

You asked the Plan to pay for the eye refraction. You say that you have worn eyeglasses since age 30 and in the past you have had some testing with other doctors and have not been denied coverage. The Plan denied your request. The Plan says Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts. Refraction is not identified as a covered benefit.

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, the Medicare rules and the Plan's rules. The file shows that you received an eye exam for a Medicare-covered eye condition and not a routine eye exam. The file shows that part of this exam was for a refraction. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on May 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for paramedic intercept services provided on May 23, 2021.

You asked the Plan to pay for the paramedic intercept services. You say that you are very ill, but you do not use an ambulance often as your husband usually transports you when you need to go to the hospital. You say that this service was due to an emergency and should be covered. The Plan denied your request. The Plan says paramedic services provided to areas other than rural New York are non-covered.

The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. 

The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic intercept services provided on May 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Levalbuterol inhaler.

You asked the Plan to pre-approve a Levalbuterol inhaler. You say that other medications give the enrollee heart palpitations. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 pre-approve a Levalbuterol inhaler.

Benefits for a Levalbuterol inhaler 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (G0439) rendered by the out-of-network (OON) provider on March 16, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by the out of network provider, without prior authorization.

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 service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the annual wellness visit (G0439) rendered by the out-of-network (OON) provider on March 16, 2021.