Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 10, 2021.

You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 physician's services provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for services with a neurosurgeon you received on April 12, 2021.
You asked the Plan to waive the deductible for the neurosurgery services. You say that you do not believe the contract says that the deductible applies to office visits. The Plan denied your request. The Plan says you were charged this deductible correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $150 deductible which applies to specialist services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible which applies to specialist services. This cost sharing is a contractual obligation that had not been met at the
time the neurosurgery services were received on April 12, 2021. Therefore, we decided that the Plan does not have to waive the deductible for services with a neurosurgeon you received on April 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you had at an outpatient hospital facility on June 30, 2021.
You asked the Plan to waive the copayment for the EKG. You say that this test was done as a precaution prior to endoscopy/colonoscopy because you were having chest pain. You believe that it should be covered. The Plan denied your request. The Plan says this service is a covered benefit, however, the allowed amount for this service ($68.80) is less than your copayment obligation. So, you are responsible for the full allowed amount for this 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 $95 copayment for non-radiological diagnostic services performed in a hospital.
You have been asked to pay a $95 copayment for the EKG. The EKG falls within the non-radiological diagnostic services performed in a hospital 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 electrocardiogram (EKG) you had at an outpatient hospital facility on June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (88304) rendered by the out-of-network (OON) provider on September 24, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the laboratory service (88304) rendered by the out-of-network (OON) provider on
September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on October 13, 2021.  You asked the Plan to pay for the bitewing x-rays. You say that you desperately need help because you have been suffering for over a year with your teeth due to the Coronavirus pandemic. The Plan denied your request. The Plan says this service exceeds the maximum allowed per period for the procedure grouping.  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, bitewing x-rays are limited to one procedure per plan year. The record shows that you received bitewing x-rays (D0274) on April 14, 2021 and your bitewing x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on October 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xiidra Dro 5%.  You asked the Plan to pre-approve Xiidra Dro 5%. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Xiidra Dro 5% is not covered under the enrollee's Medicare 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 Xiidra Dro 5%.   Benefits for Xiidra Dro 5% 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 an additional amount for eyeglasses provided on  October 21, 2021.  You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says the eyewear benefit of a $350 allowance was applied to the purchase, leaving a member responsibility of $882, which was paid at the time of purchase. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the Plan paid the maximum eyewear benefit allowance of $350. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on October 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synthroid tablets.

You asked the Plan to pre-approve Synthroid tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Synthroid tablets are not covered under the enrollee's Medicare 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 Synthroid tablets.

Benefits for Synthroid tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on September 21, 2021.

You asked the Plan to waive the copayment for the specialist visit. You say that it was a pre-operative appointment and you only saw a nurse. 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 $40 copayment for each specialist office visit. 

You have been asked to pay a $40 copayment for the specialist visit. The specialist 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 a specialist office visit provided on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on October 14, 2021.  You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain/ceramic crown. You say that you spent a lot of money on your implant crown and would like to know if the Plan can cover these services. The Plan denied your request. The Plan says these services are not covered under your plan.  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 the custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on October 20, 2021.
You asked the Plan to pay for the adjunctive test. You say that this service was performed by an in-network provider and should be covered. The Plan denied your request. The Plan says this service is not covered under your dental 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 the adjunctive pre-diagnostic test (D0431) provided on October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the hearing aids, digital, monaural, in-the-canal (ITC) (V5255) provided August 9, 2021.  You asked the Plan to provide additional payment for the hearing aids. You say that you would like the Plan to reduce the copayment for the hearing aids. The Plan denied your request. The Plan says the copayment was applied correctly.  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 contract says that there is a $1,075 copay for each Standard level name brand hearing aid.  We looked at the file and the Plan's rules. You have been asked to pay a total of $2,150 ($1,075 copayment x 2 Standard level name brand hearing aids = $2,150). This means you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to provide additional payment for the hearing aids, digital, monaural, in-the-canal (ITC) (V5255) provided August 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on October 19, 2021.
You asked the Plan to waive the copayment for an EKG. You say that diagnostic testing should have been covered as part of your wellness visit. The Plan denied your request. The Plan says diagnostic testing is not covered under a wellness visit and the copayment applied 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 $40 copayment for Medicare-covered diagnostic tests and procedures.
You have been asked to pay $30 for an EKG, which is less than your $40 copayment. An EKG 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 an electrocardiogram (EKG) provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for injections (62320) provided August 16, 2021.  You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. Insufficient documentation has been provided to support the billed services. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (62320) provided August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on September 27, 2021, to
October 8, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that you are appealing these services. 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 chiropractic services provided on September 27,
2021, to October 8, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ultrasound (76705) provided on August 11, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that the services should be covered. The Plan denied your request. The Plan says the copayments 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 $125 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.       You have been asked to pay a $62.48 copayment for an ultrasound, which is less than the $125 stated in the Plan's contract. Ultrasounds fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound (76705) provided on August 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on September 26, 2021.
You asked the Plan to pay for the ambulance services. You say that the ambulance services were medically necessary. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 16, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance services provided on September 26, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shoulder x-ray (73030) and outpatient office visit (99213) provided on July 20, 2021.  You asked the Plan to pay for the shoulder x-ray and outpatient office visit. You say that the services are not related to the enrollee's terminal condition. You also say that per Medicare, non-related services are separate from hospice care and are eligible for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.  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 the shoulder x-ray (73030) and outpatient office visit (99213) provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the mandibular partial denture (D5214) provided on October 22, 2021.  

You asked the Plan to pay for the mandibular partial denture. You say that you never received two sets of dentures. You also say that you received a temporary denture, which you had to have adjusted multiple times, and later received the permanent denture. The Plan denied your request. The Plan says your benefits for this service have been satisfied and the frequency limitation has 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, you are limited to one upper and/or one lower partial denture every five years. The record shows that you received an immediate mandibular partial denture (D5222) on June 24, 2021 and your mandibular partial denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the mandibular partial denture (D5214) provided on October 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Breztri sphere aer.  

You asked the Plan to pre-approve Breztri sphere aer. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Breztri sphere aer is not covered under the enrollee's Medicare 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 Breztri sphere aer.   

Benefits for Breztri sphere aer 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 apicoectomies of premolars (first root) (D3421), apicoectomies of molars (first root) (D3425), apicoectomies (each additional root) (D3426), and retrograde fillings (D3430) provided on July 26, 2021.
You asked the Plan to pay for the apicoectomies and retrograde fillings. You say that this was more of a surgery to remove old roots from your sinus cavity that were causing sinus issues. The Plan denied your request. The Plan says these services are not covered.
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 the
apicoectomies of premolars (first root) (D3421), apicoectomies of molars (first root) (D3425), apicoectomies
(each additional root) (D3426), and retrograde fillings (D3430) provided on July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on October 1, 2021.
You asked the Plan to reimburse you for the eyeglasses. You say that you were told by the optical provider that you had to pay up front and get reimbursed from your insurance as they did not bill the insurance plan. You say that you thought this was standard practice for vision care as you were never informed otherwise. The Plan denied your request. The Plan says the Plan does not cover eyewear provided by out-of-network providers.
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 provided by a network optical provider. We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by network optical provider. 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 reimburse you for eyeglasses provided on October 1, 2021.