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

 We decided that the Plan does not have to pay for the office visit services provided on July 15, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit services provided on July 15, 2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an outpatient hospital visit, and an outpatient evaluation provided from May 30, 2021, to June 1, 2021.

You asked the Plan to waive the copayments for an outpatient hospital visit and the outpatient evaluation. You say that the enrollee should not have to pay the copayments because of the lack of care during the services. The Plan denied your request. The Plan says they investigated the quality of care, and the proper copayments were applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $95 copayment for Visits to an Outpatient Hospital and a $40 copayment for Speech Therapy in an outpatient hospital setting. For both services the total copayment amount was $135 ($95 copayment + $40 copayment).

The enrollee has been asked to pay a $134 copayment for an outpatient hospital visit and the outpatient evaluation. An outpatient hospital visit falls within the Outpatient hospital services benefit category and the outpatient evaluation falls within the Outpatient rehabilitation services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for an outpatient hospital visit, and an outpatient evaluation provided from May 30, 2021, to June 1, 2021.

We read your letter and knows that you may have a quality of care concern. We cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray services (procedure code 77080) provided to the enrollee on August 10, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was not billed with an appropriate diagnosis.

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 77080 is "Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)." This code was billed with a diagnosis code of Z13.820, which indicates "Encounter for screening for osteoporosis." 

We find that CPT code 77080 is not supported in the medical record. Specifically, the diagnosis code used alongside this procedure code is not allowed by claim guidelines. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for x-ray services (procedure code 77080) provided to the enrollee on August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physician office services provided on October 13, 2020.  You asked the Plan to pay for the physician office services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says once the primary explanation of benefits (EOB) is received from the primary insurance provider, the claim can be reviewed for payment.  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the primary insurance provider and requested an Explanation of Benefits (EOB) for the services at issue. As the secondary insurer, the Plan cannot be held responsible for the physician office services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the physician office services provided on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 17, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 17, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the personal protective equipment (D1999), and additional periapical x-ray (D0220) provided on February 1, 2021.  You asked the Plan to pay for the dental services. You say that you advised that you only wanted services that would be covered by your insurance. You also say that the dental office performed extra procedures without consulting you. The Plan denied your request. The Plan says personal protective equipment is not listed as a covered service. The Plan says that 1 periapical x-ray is covered per calendar year. The Plan also says that  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 personal protective equipment is not among those covered under this benefit. Additionally, 1 periapical x-ray is covered per calendar year. The record shows that the frequency limit for this service has been exceeded. The record shows that the Plan paid for 1 periapical x-ray that you received on this date of service, thus exhausting the benefit. Therefore, we decided that the Plan does not have to pay for the personal protective equipment (D1999), and additional periapical x-ray (D0220) provided on February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on October 25, 2021.

You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says members must schedule and order hearing aids through the Plan's in-network hearing provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when obtained from a provider in the Plan's hearing vendor network. 

We looked at the file and the Plan's rules. The file shows that the hearing aids were not obtained from a provider in the Plan's hearing vendor network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on October 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an Esophagogastroduodenoscopy (43239) provided on July 29, 2021.  You asked the Plan to waive the copayment for the Esophagogastroduodenoscopy. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $295 copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers.   You have been asked to pay a $295 copayment for an Esophagogastroduodenoscopy. The Esophagogastroduodenoscopy falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 an Esophagogastroduodenoscopy (43239) provided on July 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided April 20, 2021.  You asked the Plan to waive the copayment for the non-emergency ambulance service and ground mileage. You say that the enrollee cannot afford the cost of the service. 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 $230 copayment for each one-way Medicare-covered ground ambulance trip.  You have been asked to pay a $230 copayment for the non-emergency ambulance service and ground mileage. The non-emergency ambulance service and ground mileage falls within the Ambulance 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 the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on February 18, 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 as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for eyeglasses provided on October 13, 2021.  You asked the Plan to pay for the eyeglasses. You say that you were not aware you needed to take your prescription to certain locations. The Plan denied your request. The Plan says you must use a doctor in our vision network.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when you use a doctor in the Plan's vision network.  We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by a doctor in the Plan's vision network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for pathology services (81479) provided on September 2, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for pathology services. You say that the provider, who is an in-network provider, ordered a blood biopsy in order to assist determining the optimal treatment options for their patient. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and based on the documentation submitted, we have determined that the services rendered to the member are not urgent or emergent, nor were they approved in advance by a network provider. The Plan also says that they need an approved referral from the enrollee's primary care physician (PCP).  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 pathology services (81479) provided on September 2, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on April 27, 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 as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate place of service 11. According to claims history, the specimen was obtained in an Assisted Living Facility POS 13. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on June 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an onabotulinumtoxina injection (J0585) provided on April 27, 2021.  You asked the Plan to waive the coinsurance for the onabotulinumtoxina injection. You say that the services should be covered as you received a letter stating they would be covered under your Part D Plan. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services 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 20% coinsurance for Medicare Part B prescription drugs.     You have been asked to pay a 20% coinsurance for an onabotulinumtoxina injection (allowed is $1,211.81 x 20% = $242.36). This injection was provided in an outpatient setting, which is why it was billed under Part B.  Onabotulinumtoxina injections fall within the Medicare Part B prescription drugs 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 the onabotulinumtoxina injection (J0585) provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81286, 81238, 81411, and 81410) provided on April 24, 2021.

You asked the Plan to pay for codes 81286, 81238, 81411, and 81410. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (81286, 81238, 81411, and 81410) provided on April 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided March 23, 2021.  You asked the Plan to pay for the periodontal maintenance. You say that you were advised this service would be covered at 100% as a preventative service. The Plan denied your request. The Plan says the periodontal maintenance was processed correctly.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the periodontal maintenance with 30% coinsurance after the $100 deductible is met. When you see a non-participating provider, you may be responsible for any difference between what the Plan's dental vendor pays and the amount the non-participating provider charges.  We looked at the file and Medicare rules. The periodontal maintenance is covered under periodontics which is a considered a comprehensive service. At the time your claim was processed you had not yet met your annual deductible. Therefore, the Maximum Contract Allowance ($83) was applied to your deductible. Additionally, the provider may charge you for the difference between the Maximum Contract Allowance and the total Submitted Fee charged by the non-participating provider.  Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided March 23, 2021.   Your complaint about potentially having incorrect or outdated information about plan benefits 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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy services provided by a physical therapy assistant on December 10, 2020.  You asked the Plan to pay for the physical therapy services provided by a physical therapy assistant. You say that you would like this claim to be reprocessed. The Plan denied your request. The Plan says the billed services were not supported. The Plan also says that the records indicate that the service is performed by a physical therapist assistant in a home health or hospice setting.  The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.     We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services provided by a physical therapy assistant have not been met. Specifically, the billing provider is a nurse practitioner (NP), and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided by a physical therapy assistant on December 10, 2020.