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

 We decided that the Plan does not have to reduce the copayment for a medical eye exam (92014) provided on September 14, 2021.  

You asked the Plan to reduce the copayment for a medical eye exam. You say that you feel this should be covered because this was a routine vision exam and should be billed at $15 copay not a $45 copay. The Plan denied your request. The Plan says the copayment you are being charged is correct.  

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 visit for services to diagnose and/or treat a disease or condition of the eye.   

You have been asked to pay a $45 copayment for a medical eye exam. The records show that the diagnosis for your visit was nuclear cataract in both eyes. The EOC confirms $45 is the required copayment for this service. A medical eye exam falls within the vision 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 reduce the copayment for a medical eye exam (92014) provided on September 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on May 9, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.  The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any durable medical equipment (DME) item to a beneficiary.  We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on May 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chiropractic services provided on February 23, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for chiropractic services. You say that you are requesting payment of this claim. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 chiropractic services provided on February 23, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit provided on August 13, 2021.  You asked the Plan to waive the copayment for the office visit. You say that this should be covered because you went in for an annual physical with your PCP and no extra services were provided. 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 $10 copayment for each covered visit or consultation in an outpatient location with your primary care physician (PCP) or other primary care provider.   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. The medical record shows the visit was for abnormal weight loss. 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 office visit provided on August 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a psychotherapy visit provided on May 26, 2021.  You asked the Plan to waive the coinsurance for psychotherapy visit. You say that you feel that you are entitled to 80% of the claims that you have filed. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.  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 50% coinsurance for out-of-network psychotherapy visit. The allowed amount of the claim is $146.67, resulting in a coinsurance amount of $73.34. Therefore, the Plan reimbursed you $73.33.  You have been asked to pay 50% coinsurance for psychotherapy visit. Psychotherapy visit falls within the Outpatient Mental Health 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 coinsurance for a psychotherapy visit provided on May 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided in an outpatient setting on September 30, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you are being charged for 2 prescriptions that the physician sent you home with. You say that you were given no option to have these prescriptions filled elsewhere. You say that these are emergency medications. You also say that these medications should be covered due to the circumstances. The Plan denied your request. The Plan says self-administered drugs are not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for 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 pay for the self-administered drugs (A9270) provided in an outpatient setting on September 30, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the root canal (D3330) provided on August 26, 2021.  You asked the Plan to pay for the dental service. You say that you received a provider directory in September 2020. You say that the provider in this case was listed as in network. You also say that this service should be covered at the in network rate. The Plan denied your request. The Plan says the provider in this case is out of network.  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 root canal is listed as covered, out of network dentists may bill you for any amount greater than what the Plan pays the provider. Therefore, we decided that the Plan does not have to pay for the root canal (D3330) provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to hold the enrollee harmless for the subsequent hospital care services received by the enrollee on July 14, 2021 and July 16, 2021.  You asked the Plan to hold the enrollee harmless for the subsequent hospital care services. You say that these services should be covered because the enrollee was seen by the doctor while in inpatient care. The Plan denied your request. The Plan says that the services received are not payable.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.  The enrollee was referred for the subsequent hospital care services by a contract provider. The file does not show that the plan provided notice that the subsequent hospital care services would not be covered. Under Medicare rules, this means the subsequent hospital care services is considered approved by the plan. Therefore, we decided that the Plan has to hold the enrollee harmless for the subsequent hospital care services received by the enrollee on July 14, 2021 and July 16, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the cost share for the chemodenervation of muscle and the Part B drug provided on September 14, 2021.  You asked the Plan to reduce the cost share for the chemodenervation of muscle and the Part B drug. You say that you should have a $30 copayment for the specialist. 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 $30 copayment for provider and professional services at an in-network specialist's office and 20% coinsurance for Medicare Part B covered drugs at an in-network specialist's office.   You have been asked to pay a $30 copayment for the chemodenervation of muscle and $121.60 which is 20% of the allowed amount for the Part B drug. The allowed amount is $608. ($608 x 20% = $121.60). The chemodenervation of muscle falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Part B drug falls within the "Medicare Part B prescription drugs" benefit category. The record shows the Part B drug is considered a separate service.   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 cost share for the chemodenervation of muscle and the Part B drug provided on September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), 3 additional periapical x-rays (D0230), partial upper denture (D5213), and partial lower denture (D5214) provided from  October 14, 2020, to September 10, 2021.  You asked the Plan to pay for the periapical x-rays, and partial dentures. You say that the website shows you have the preferred provider organization (PPO) copay plan. You say that it does not say anywhere that no benefits or health maintenance organization (HMO). The Plan denied your request. The Plan says periapical x-rays are not listed as covered services. The Plan also says that partial dentures are not listed as covered services either.  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 periapical x-rays and partial dentures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), 3 additional periapical x-rays (D0230), partial upper denture (D5213), and partial lower denture (D5214) provided from October 14, 2020, to September 10, 2021.
Appeal type: Drugs
Decision: Partially Favorable

 We decided that the Plan has to waive the coinsurance for the chemotherapy administration. We decided that the Plan does not have to waive the coinsurance for the chemotherapy drug.   You asked the Plan to waive the coinsurance for the chemotherapy drug and administration. You say that the Rituximab shot was a Part D medication, and it should not be billed as a Part B drug. The Plan says that you have been asked to pay the correct cost-sharing amount.  We decided that the Plan has to waive the coinsurance for the chemotherapy administration.   The record shows that administration of covered Part B prescription drugs is included in the total cost.   The Plan says you must pay $95.15 for the chemotherapy administration. Based on the Plan contract, however, you cannot be asked to pay more than $0 for the chemotherapy administration. Therefore, we decided that the Plan has to waive the coinsurance for the chemotherapy administration.   We also decided that the Plan does not have to waive the coinsurance for the chemotherapy drug.  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 $1,961.10 which is 20% of the allowed amount for the chemotherapy drug. The allowed amount is $9,805.51. ($9,805.51 x 20% = $1,961.10). Therefore, we decided that the Plan does not have to waive the coinsurance for the chemotherapy drug.  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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services provided on October 15, 2020.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed code cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The claim lists a place of service as an independent laboratory. The records do not indicate the specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for electrical stimulation and therapeutic injections/procedures (G0283, 97750, 96372, 97112, J3490, J3411, J3415, J3490, J7999, 97016) provided August 10, 2021.  You asked the Plan to pay for electrical stimulation and therapeutic injections/procedures. You say that the services provided were medically necessary. The Plan denied your request. The Plan says these services are not covered benefits.  The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services by an NP or PA only when that NP/PA may perform physical therapy services under State law. The rules also say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. The rules also say that Prolotherapy is not a covered benefit.  We looked at the file and Medicare rules. Based on a review of the file and publicly available records, we find that the physical therapy services at issue were rendered by a 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. Prolotherapy is not a covered benefit of Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage of electrical stimulation and therapeutic injections/procedures have not been met. Therefore, we decided that the Plan does not have to pay for electrical stimulation and therapeutic injections/procedures (G0283, 97750, 96372, 97112, J3490, J3411, J3415, J3490, J7999, 97016) provided August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for panoramic radiographic image (D0330) and an intraoral periapical first radiographic image (D0220) provided on September 13, 2021.  You asked the Plan to pay for panoramic radiographic image and an intraoral periapical first radiographic image. You say that you visited your dentist due to a cavity on the inside of your tooth and you wanted the cavity filled or a crown fitted. You also say that you believe the dentist fulfilled all the requirements under a comprehensive oral evaluation and bitewings on your tooth which are covered under the terms of your Plan. The Plan denied your request. The Plan says the requested services are not listed as a covered service. 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 panoramic radiographic image (D0330) and an intraoral periapical first radiographic image (D0220) provided on September 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiology services provided on September 14, 2021.  You asked the Plan to pay for the services provided. You say that you are being charged additional fees. The Plan denied your request.   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 $50 copay for basic radiological services provided in an outpatient hospital.   You have been asked to pay a $50 copay for the services provided. The services fall within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for the radiology services provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assisted living facility services provided on September 2, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the assisted living facility services. You say that it is the nursing facility's responsibility to obtain authorization which should cover the rendering physician's medical treatment. You say the service was medically necessary. 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 records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the assisted living facility services provided on September 2, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on September 24, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that this office visit was required by your doctor prior to performing your colonoscopy. You say the office visit should be totally covered as an integral part of the procedure. 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 $45 copayment for provider and professional services at an in-network specialist's office.

You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the office visit is considered a separate service. 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 specialist office visit provided on September 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Testosterone gel 1.62% for the enrollee.  You asked the Plan to pre-approve the gel. You say that this is medically necessary. The Plan denied your request. The Plan says drugs covered under Part D are not eligible for coverage under the Part B benefit.  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 Testosterone gel 1.62% for the enrollee.