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

We decided that the Plan does not have to waive the copayment for the primary care physician office visit provided on May 17, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you went for a wellness yearly visit, which is a free visit. You say you did not have other conversations with the doctor about hyperlipidemia and atrial fibrillation. 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 $10 copayment for a primary care provider office visit. The record shows you received an annual wellness visit; however, the record shows that you also received new treatment services while you were there. Since the services provided went beyond the scope of an annual visit, you have been asked to pay a $10 copayment for the office visit. The office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 primary care physician office visit provided on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (on claim 21063001920412400121) provided on June 24, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON lab services. You say that you checked the online provider directory and it showed this lab as being in-network. The Plan denied your request. The Plan says this lab is not a network provider with your specific plan.
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 lab services (on claim 21063001920412400121) provided on June 24, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on November 16, 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 the enrollee did not have prior authorization.
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says that for outpatient laboratory services, providers are to obtain prior authorization. The Plan did not pre-approve the services at issue. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on July 12, 2021.
You asked the Plan to pay for the dental services. You say that you had to get a second opinion. You say that after bringing several concerns to your previous dentist, they advised that everything was fine. You say that your second opinion says otherwise. You also say that your previous dentist was very rough and maybe dug out one of your old fillings, so they had to replace it. The Plan denied your request. The Plan says comprehensive oral evaluation is covered once every 3 calendar years. The Plan says that 1 panoramic or complete series x-ray is covered per calendar year. The Plan also says that the frequency limits have been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on June 5, 2019. The record shows that the Plan paid for the complete series x-ray that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on July 12, 2021.
Your complaint about your previous dentist 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on May 26, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you were in the ER for hours and were on a gurney the whole time. You said that you were never offered anything to eat or drink. You do not think you should have to pay this copayment. 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 $110 copayment for emergency room visits.
You have been asked to pay a $110 copayment for the ER visit. This copayment applies regardless of whether or not you are satisfied with the services you received. 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 May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Hepatitis A vaccination you received on June 28, 2021.
You asked the Plan to pay for the Hepatitis A vaccination. You say that this vaccination was medically necessary. The
Plan denied your request. The Plan says this vaccination is not covered under your medical benefits.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Hepatitis A vaccination.
The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Hepatitis A vaccination.
Therefore, we decided that the Plan does not have to pay for the Hepatitis A vaccination you received on June 28, 2021.
Benefits for the Hepatitis A vaccination 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services coded as 99601 provided on April 2, 2021.
You asked the Plan to pay for the home infusion services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim as billed is not covered per Medicare.
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, the CPT Code Manual definition of code 99601 is home infusion/specialty drug administration, per visit (up to 2 hours). We find that CPT code 99601 is not supported in the medical record. Specifically, this code has an "I" status indicator which indicates that Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion services coded as 99601 provided on April 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on June 24, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON lab services. You say that you checked the online provider directory and it showed this lab as being in-network. The Plan denied your request. The Plan says this lab is not a network provider with your specific plan.
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 lab services provided on June 24, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the services needed in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness and falls after a recent admission for medical management of subdural hematoma after a motor vehicle accident. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy and the esophagogastroduodenoscopy (EGD) procedures you had at an ambulatory surgery center on August 9, 2021.
You asked the Plan to waive the copayment for the colonoscopy and EGD. You say that your doctor told you to have these two procedures done at the same time. You said that you were not made aware that there would be a 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 $250 copayment for outpatient surgery and services at an ambulatory surgical center.
You have been asked to pay a $250 copayment for the colonoscopy and EGD. These services fall within the outpatient surgery and services at an ambulatory surgical center 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 diagnostic colonoscopy and the esophagogastroduodenoscopy (EGD) procedures you had at an ambulatory surgery center on August 9, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision equipment purchased from a provider not contracted with Medicare.
You asked the Plan to pay for the vision equipment. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no payment is allowed for a provider who does not participate with Medicare.
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 the vision equipment purchased from a provider not contracted with Medicare.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON power scooter. You say that you had a stroke and cannot use your left side. You say that your foot has dropped, and you are not mobile. The Plan denied your request. The Plan says there are participating providers who can supply the item being requested.
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 a power scooter to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for lab services you received on July 19, 2021.  You asked the Plan to waive the copayment for the lab services. You say that this was a covered service and you should not have a copayment. 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 $10 copayment for lab services.   You have been asked to pay a $10 copayment for the lab 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 copayment for lab services you received on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the nerve conduction test (code 95913) you received from a chiropractor on July 22, 2021.  You asked the Plan to pay for the nerve conduction test. You say that this test showed that you have carpal tunnel syndrome, so this service should be covered. The Plan denied your request. The Plan says nerve conduction tests are not covered services when provided by a chiropractor.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the nerve conduction test (code 95913) you received from a chiropractor on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chiropractic services provided from April 19, 2021, to June 1, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services are not covered when billed by a chiropractor.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The file shows that you received an office visit on April 19, 2021, and June 1, 2021. You received electric stimulation on April 20 and 23, 2021. You received a cervical spine x-ray on April 19, 2021. These services are not covered when provided by a chiropractor. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided from April 19, 2021, to June 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on July 23, 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 due to the enrollee's hospice status at the time of service, 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 imaging services provided to the enrollee on July 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the static or dynamic ankle foot orthosis (L4397) provided July 7, 2020.  You asked the Plan to pay for the static or dynamic ankle foot orthosis. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the enrollee does not have a Medicare-covered diagnosis for the requested equipment.  The Plan must follow Medicare rules. Medicare rules say that an ankle foot orthosis coded as L4397 is only covered for certain diagnoses.  We looked at the file and Medicare rules. In this case, the enrollee does not have a diagnosis listed in the Medicare rules section as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of the static or dynamic ankle foot orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the static or dynamic ankle foot orthosis (L4397) provided July 7, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services provided on December 18, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for the OON psychotherapy services. You say that the provider shouldn't be penalized for the hospital's failure to get authorization. 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. It is the provider's obligation to confirm insurance coverage prior to rendering services. 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 psychotherapy services provided on December 18, 2020, 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 skilled nursing facility (SNF) services you received from April 1, 2021, to April 23, 2021.  You asked the Plan to waive the copayment for the SNF services. You say that if you had been discharged earlier, you would not have had a copayment. The Plan denied your request. The Plan says yo 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 $160 copayment per day for days 21-51 for skilled nursing facility services.   Records show that you were in the SNF for 23 days.  You were not charged a copayment for the first 20 days.  You were charged a $160 copayment per day for the last three days, for a total of $480. This copayment applies regardless of the reason for the length of your stay. 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 skilled nursing facility (SNF) services you received from April 1, 2021, to April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for topical fluoride varnish application service (code D1260) provided on April 8, 2021.
You asked the Plan to pay for the topical fluoride varnish application service. You say that were advised that this provider was in-network. The Plan denied your request. The Plan says it has made a one-time exception and covered all of the dental services received on this date of service except for the topical fluoride varnish application. The Plan says that this service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for topical fluoride varnish application service (code D1260) provided on April 8, 2021