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

 We decided that the Plan does not have to waive the copayments for the vision exam (92012, 92083, 92250) and the ultrasound of the cornea (76514) provided on October 1, 2021.  You asked the Plan to waive the copayments for the vision services. You say that you feel this was preventative care and should be covered at no cost to you. The Plan denied your request. The Plan says these claims were processed correctly, and your cost-share for these covered services was assessed in accordance with your contract. Your copayment for the ultrasound is less than your required copayment because the Plan's allowed cost for this service in this case is less than the required copayment.  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 $35 copayment for a medical eye exam and a $175 copayment for advanced radiology services. Documentation shows that the medical eye exam was provided for medical purposes to address a pre-existing condition. This means that the exam in question is neither routine nor preventative. You have been asked to pay a $35 copayment for the medical eye exam and an $8.56 copayment for the ultrasound. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the vision exam (92012, 92083, 92250) and the ultrasound of the cornea (76514) provided on October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the immediate upper denture (D5130), immediate lower denture (D5140), alveoloplasty with extractions for 1 to 3 teeth per quadrant (D7311), and alveoloplasty with extractions for 4 or more teeth per quadrant (D7320) provided on September 16, 2021.  You asked the Plan to pay for the immediate dentures and alveoloplasties. You say that the dental office gave you the specific codes to verify with your insurance. You say that you also advised the plan representative that the provider was out of network. You say that the plan representative advised that you would receive a prorated amount for the covered services. You also say that The Plan denied your request. The Plan says the services you received are not listed as covered dental services. The Plan says that dental services received out of network are not covered. The Plan also says that you were advised  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 immediate dentures and alveoloplasties are not among those covered under this benefit, regardless of the provider's network status. Therefore, we decided that the Plan does not have to pay for the immediate upper denture (D5130), immediate lower denture (D5140), alveoloplasty with extractions for 1 to 3 teeth per quadrant (D7311), and alveoloplasty with extractions for 4 or more teeth per quadrant (D7320) provided on September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lens upgrades including anti-reflective coating (V2750), UV lens (V2755), polarization (V2762) and polycarbonate coating (V2784) for the eyeglasses purchased on October 6, 2021.  You asked the Plan to pay for the lens upgrades. You say that these services were medically necessary after your cataract surgery. The Plan denied your request. The Plan says that base lenses and frames are covered following cataract surgery. Lens add-ons are generally not covered. The Plan has paid for the cost of the base lenses/covered items, and you are being asked to pay an amount that is within the range you agreed to pay when you purchased the lenses.  The Plan must follow Medicare rules. The rules say that for beneficiaries with pseudophakia, coverage is limited to one pair of eyeglasses or contact lenses after each cataract surgery with insertion of an IOL. Use of polycarbonate or similar material (V2784) or high index glass or plastic (V2782, V2783) for indications such as light weight or thinness will be denied as a noncovered deluxe feature. Scratch resistant coating (V2760), mirror coating (V2761), polarization (V2762), deluxe lens feature (V2702) and progressive lenses (V2781) will be denied as noncovered.  The Plan offers a supplemental (extra) benefit to cover routine vision services not covered by Original Medicare. This benefit provides an annual allowance of $220 for a combination of routine prescription contacts, routine prescription lenses, routine vision frames and/or upgrades, such as tinting. Any amount billed by the provider above the allowance would be your responsibility.  The services you asked the Plan to pay for are not covered by Medicare. Based on the documentation provided, it appears that the Plan has decided to cover these lenses under your routine vision benefit in order to cover part of the cost of the add-on features in addition to the base lens. This benefit covers a maximum of $220 per year, and you are responsible for any costs that exceed this allowance. Therefore, we decided that the Plan does not have to pay for the lens upgrades including anti-reflective coating (V2750), UV lens (V2755), polarization (V2762) and polycarbonate coating (V2784) for the eyeglasses purchased on October 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM).  You asked the Plan to pay for the CGM. 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 covered.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid physician order for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (83516,86235)  provided on July 8, 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 you had to get all tests done through the Plan, nor that you needed any sort of authorization before doing any test or medical procedures outside of the Plan. You also say that the providers did not inform you that the testing would be done in a different laboratory than the Plan requires, nor did they try to contact the Plan for any authorization. The Plan denied your request. The Plan says these services were not authorized by the Plan, and this is a non-contracted provider who performed services to the member without prior authorization from the 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 laboratory services (83516,86235)  provided on July 8, 2021, by an out-of-network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (72148) rendered on September 15, 2021.  You asked the Plan to waive the copayment for a magnetic resonance imaging. You say that due to the office staff not advising you that you would have a copayment for an MRI, you should not be obligated to pay. You also say they did not provide accurate information. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 copayment for Medicare-covered MRI, MRA, and Angiogram at a freestanding provider.   You have been asked to pay a $75 copayment for a magnetic resonance imaging. A magnetic resonance imaging falls 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 a magnetic resonance imaging (72148) rendered on September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the facedown recovery system (E1399) provided April 3, 2021 to April 4, 2021.  You asked the Plan to pay for the facedown recovery system. You say that you were told by one of the agents that this equipment was covered and was advised to order the equipment from another company due to time constraint. The Plan denied your request. The Plan says this equipment is a precautionary device and can be used for other purposes other than for treatment of an illness or injury.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the facedown recovery system (E1399) provided April 3, 2021 to April 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 23, 2021 to June 7, 2021.  You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the Request for Anticipated Payments (RAP) must be submitted within five days of the start of care. The documentation shows that the RAP was submitted outside the timely timeframe. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from May 23, 2021 to June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided by a participating provider on September 27, 2021, to September 28, 2021.  You asked the Plan to pay for periodontal scaling and root planing. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for D4341 has already been exhausted.  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 one periodontal scaling and root planning per quadrant every three years.  We looked at the file and Medicare rules. Evidence was provided to show that D4341 was exhausted on July 31, 2019. Based on this information, we decided that the Plan's rules for coverage of periodontal scaling and root planing have already been exhausted. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided by a participating provider on September 27, 2021, to September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (G0283) vasopneumatic devices
(97016) neuromuscular reeducation (97112) administration of injections (96372) thiamine injection (J3411)
pyridoxine injection (J3415) Unclassified drugs (J3460) compounded drug, not otherwise classified (J7999)
provided on August 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient services. You say that the medical records provided support the
necessity of the services in dispute. The Plan denied your request. The Plan says these services are not
Medicare covered benefits. Enrollee's must receive their medical services from an in-network provider with the
exception being urgent or emergent services. Non-emergent services with non-contracted providers require
prior authorization before services being rendered.
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. Review of the file and publicly available records, we find that the physical therapy
services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the
State of Oklahoma. The multiple drug codes reported on this claim refer to a pre-filled compounded
drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified
code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are
not paid as billed, the drug administration code, 96372, also cannot be paid. 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
electrical stimulation (G0283) vasopneumatic devices (97016) neuromuscular reeducation (97112)
administration of injections (96372) thiamine injection (J3411) pyridoxine injection (J3415) Unclassified drugs
(J3460) compounded drug, not otherwise classified (J7999) provided on August 26, 2021 by an out-of-network
(OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support,
emergency transport (A0429) provided April 26, 2021.
You asked the Plan to waive the copayment for the emergency ambulance service. You say that you have never
had to pay a copay for ambulance 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 $275
copayment per member transport for Medicare-covered ground and air ambulance benefits.
You have been asked to pay a $275 copayment for the emergency ambulance service. The emergency
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (86331, 83516, 86606) provided on July
8, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that you did not understand how the Plan worked
when you first became a member. The Plan denied your request. The Plan says these services were not
authorized.
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 laboratory services (86331, 83516, 86606)
provided on July 8, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas device therapy and vitamin injections provided
on July 13, 2021, and billed with codes 96372, 97016, 97112, 97750, G0283, J3411, J3415, J3490, and J7999.
You asked the Plan to pay for the Sanexas device therapy and vitamin injections. 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
covered.
The Plan must follow Medicare rules. Medicare rules say that in order for physician-provided drugs to be
covered, the medical records must document the name of the drug administered as well as the dosage. The rules
also say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or
under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a
nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy
services under State law.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Sanexas device therapy and vitamin injections have not been met. Specifically, the record does
not contain documentation of the dosage and type of drug administered in each injection, which is required by
Medicare for these services to be reimbursed. Additionally, after review of the file and publicly available
records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not
licensed to provide physical therapy in the State of Oklahoma. Therefore, we decided that the Plan does not
have to pay for the Sanexas device therapy and vitamin injections provided on July 13, 2021, and billed with
codes 96372, 97016, 97112, 97750, G0283, J3411, J3415, J3490, and J7999.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a surgery provided on June 23, 2021.
You asked the Plan to waive the deductible for the surgery. You say that in prior years for the same service you never had any out-of-pocket expenses. The Plan denied your request. The Plan says the enrollee did not hit their deductible prior to the date of service. The proper deductible was applied to the service.
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 $1,484 deductible for most Part A in-network and out-of-network services. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Prior to the date of service there was $0 paid towards the deductible. The amount allowed for this service was $1,293.88. Therefore, the $1,293.88 was billed towards the deductible leaving a balance of $190.12 ($1,484 starting deductible - $1,293.88 paid deductible) left to pay on the deductible.
You have been asked to pay a $1,293.88 deductible for the surgery. The deductible for the surgery falls within the What is your plan deductible 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 deductible for a surgery provided on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 14, 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 covered.
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 April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for total electric hospital bed (E0297) roam rubber mattress (E0272) miscellaneous durable medical equipment (E1399) DME delivery, set up, and/or dispensing service component (A9901) sales tax (S9999) purchased March 10, 2021.  You asked the Plan to pay for the hospital bed. You say that the electric hospital bed was ordered due to decreased mobility and other underlying medical issues. You request reconsideration of the denial of payment as was medically necessary for him to have this bed. The Plan denied your request. The Plan says the provider is not certified for Medicare. Enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services.  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 total electric hospital bed (E0297) roam rubber mattress (E0272) miscellaneous durable medical equipment (E1399) DME delivery, set up, and/or dispensing service component (A9901) sales tax (S9999) purchased March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99203) provided October 1, 2021.  You asked the Plan to pay for the chiropractic service. You say that you would like the Plan to consider this an exception and reimburse you for your out-of-pocket expense on the grounds that you acted sensibly and responsibly. The Plan denied your request. The Plan says this service is not covered when rendered 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 outpatient office visit (99203) provided October 1, 2021.