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

 We decided that the Plan does not have to pay for the chest x-ray (71045) provided on April 29, 2021.  You asked the Plan to pay for the x-ray. You say that the service should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on April 18, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71045) provided on April 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgery to remove excess skin.  You asked the Plan to pre-approve surgery to remove excess skin. You say that this service is necessary for your emotional health. The Plan denied your request. The Plan says this appears to be cosmetic surgery and is not a covered service.  The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.    We looked at the file and Medicare rules. In this case, the medical documentation indicates that the requested surgery would not be performed for a medical reason but would be entirely cosmetic in nature. Based on this information, we decided that Medicare rules for coverage of surgery to remove excess skin have not been met. Therefore, we decided that the Plan does not have to pre-approve surgery to remove excess skin.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for CPAP device supplies (A7030, A7031, A7037, A7038) rendered from July 7, 2021, to July 13, 2021.  You asked the Plan to waive the copayments for continuous positive airway pressure (CPAP) device supplies. You say that the provider charged your debit card and placed the order for a new continuous positive airway pressure (CPAP) device. You also say the provider cancelled the order the next day due to an outstanding balance that you were not aware of. 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 20% coinsurance for durable medical equipment (DME) and related supplies.   You have been asked to pay $41.23 in coinsurance, which is 20% of the allowed amount for continuous positive airway pressure (CPAP) device supplies rendered on July 7, 2021 ($206.16 allowed amount x 20% coinsurance = $41.23). You have also been asked to pay $41.23 in coinsurance, which is 20% of the allowed amount for CPAP device supplies rendered on July 13, 2021 ($206.16 allowed amount x 20% coinsurance = $41.23). CPAP device supplies fall within the Durable Medical Equipment (DME) and Related 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 copayments for CPAP device supplies (A7030, A7031, A7037, A7038) rendered from July 7, 2021, to July 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics (L3215).  You asked the Plan to pre-approve foot orthotics. You say that the requested item is medically reasonable and necessary. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3215).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for arthrocentesis and does not have to waive the coinsurance for a Medicare Part B drug provided on June 29, 2021.  You asked the Plan to waive the copayment for arthrocentesis and to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 specialist visits. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.   You received arthrocentesis on June 29, 2021. Therefore, you are responsible to pay the $30 copayment.   You received a Medicare Part B drug on June 29, 2021. The allowed amount is $1,004.40 and 20% of that is $200.88.   The total amount you owe is: $230.88.   You have been asked to pay the total amount of $230.88 for arthrocentesis and a Medicare Part B drug. Arthrocentesis falls within the physician/practitioner services, including doctor's office visits benefit category. A Medicare Part B drug falls 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 copayment for arthrocentesis and does not have to waive the coinsurance for a Medicare Part B drug provided on June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the services you had with an otolaryngologist on June 1, 2021.  You asked the Plan to waive the cost sharing for the otolaryngology services. You say that you think that the charges for these services are too high considering the length of time you spent with the doctor. The Plan denied your request. The Plan says you had not yet met your deductible at the time of these services.  In addition, after the deductible was met with this claim, you were assessed the appropriate coinsurance on the remainder.  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 $192 deductible for medical services. After the deductible is met, you pay 4% coinsurance for specialist services.   The allowed amount these services based on the provider's contract with the Plan is $193.87. Because you have a $192 deductible that applies to specialist services, that is your responsibility.  According to your contract, after you meet the deductible, you are required to pay 4% coinsurance for specialist services.  This 4% coinsurance is applied to the $1.87 above the $192 deductible, meaning that your additional coinsurance is $.07.  Your deductible and coinsurance together equal $192.07, which is exactly what you are being charged. 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 cost sharing for the services you had with an otolaryngologist on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the deep sedation (D9223, D9222), therapeutic parental drugs (D9612), and surgical placement of implant body (D6010), provided on April 27, 2021.  You asked the Plan to pay for the deep sedation, therapeutic parental drugs, and surgical placement of implant body. You say that the services were medically necessary. The Plan denied your request. The Plan says these services are not covered benefits.  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. Specifically, the services obtained are not listed in the Plan's benefit chart. This means the services are not covered. Therefore, we decided that the Plan does not have to pay for the deep sedation (D9223, D9222), therapeutic parental drugs (D9612), and surgical placement of implant body (D6010), provided on April 27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for individual psychotherapy (90834) provided April 7, 2021 to July 28, 2021.  You asked the Plan to pay for the psychotherapy. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says a licensed professional counselor is not a part of the Medicare program and is not eligible for payment under Medicare.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for individual psychotherapy (90834) provided April 7, 2021 to July 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ground transportation (A0428, A0425) rendered on June 17, 2021.  You asked the Plan to waive the copayment for ground transportation. You say that you did not have a ride home from the emergency department, so the hospital arranged for an ambulance to take you home. 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 $200 per one-way trip for each Medicare-covered ambulance service.   You have been asked to pay a $200 copayment for ground transportation. Ground transportation 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 ground transportation (A0428, A0425) rendered on June 17, 2021.   Your complaint about potentially being informed the hospital would pay for your ambulance trip home due to a slip up in getting the results of a service 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the injection of a drug or substance into a vein for therapy, diagnosis, or prevention (96374) rendered from April 27, 2021, to May 25, 2021.  You asked the Plan to waive the copayments for the injection of a drug or substance into a vein for therapy, diagnosis, or prevention. You say that your provider prescribed injections for five successive weeks. You also say that you asked the provider before she put the order in to get pre-approval on the procedure. You also say that you were told by the nurses that all was pre-approved and not to worry. The Plan denied your request. The Plan says you were charged the correct copayment 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 $250 copayment for Medicare-covered surgery or other services provided to you at an ambulatory center, including but not limited to hospital or other facility charges and physician or surgical charges.   You have been asked to pay a $203.88 copayment for each of the five services of injections of a drug or substance into a vein for therapy, diagnosis, or prevention, which is less than the $250 copayment for each service. This totals $1,019.40 ($203.88 x 5 = $1,019.40). The injection of a drug or substance into a vein for therapy, diagnosis, or prevention falls within the Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The records show that there was pre-approval for these services, however, there are cost sharing amounts that do apply. 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 injection of a drug or substance into a vein for therapy, diagnosis, or prevention (96374) rendered from April 27, 2021, to May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Guardant 360 genetic testing provided on May 21, 2021.  You asked the Plan to pay for the Guardant 360 genetic testing. 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. Providers must report services with the appropriate CPT code.  We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Therefore, we decided that the Plan does not have to pay for the Guardant 360 genetic testing provided on May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the neuropathy support supplement purchased on April 10, 2021.  You asked the Plan to pay for the neuropathy support supplement. You say that you ordered the supplements and the pain decreased by over 90% without prescribed medication. You say that this works for you and the claim should be reconsidered for reimbursement. The Plan denied your request. The Plan says the neuropathy supplement, Alpha Lipoic Acid, is not listed as a covered item.  You have a $550 Pick Your Perks Benefit that is available for eligible over-the-counter items. The neuropathy support supplement is not listed as an eligible item. Therefore, we decided that the Plan does not have to pay for the neuropathy support supplement purchased on April 10, 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 August 16, 2021.  You asked the Plan to pay for the dental service. You say that you are on a fixed income. You say that you normally get a regular x-ray and cleaning with no issues. You say that you feel you are not responsible for this bill. You say that you did not request the additional x-ray. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says 1 set of bitewing x-rays are covered per calendar year. The Plan also says that the frequency limit 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 and bitewing x-rays are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for bitewing x-rays that you received on February 8, 2021. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on August 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for home health services (procedure code 99601) provided to the enrollee on April 13, 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 code is not valid for Medicare purposes.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 99601 is "Home infusion/specialty drug administration, per visit (up to 2 hours)."  We find that CPT code 99601 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 home health services (procedure code 99601) provided to the enrollee on April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the vision supply, accessory and/or service component (V2797) provided July 13, 2021.  You asked the Plan to pay for the lenses for routine eyewear. You say that the doctor's share of your appointment was covered so you do not understand why the eyewear is not. The Plan denied your request. The Plan says the routine eyewear lenses were purchased from a provider who is not part of your vision plan and therefore they are not covered.  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. The Plan covers these services when they are provided by a Plan Vision network provider.  We looked at the file and the Plan's rules. In this case the lenses were purchased from a provider who is not part of the Plan Vision network. Based on this information, we decided that the Plan's rules for coverage of the lenses for routine eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the vision supply, accessory and/or service component (V2797) provided July 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the endoscopy procedure (43235) provided on June 1, 2021.  You asked the Plan to waive the copayment for the endoscopy. You say that you were scheduled for an endoscopy and followed the pre-procedure preparations, but your procedure had to be aborted due to food in your stomach. You were scheduled to return the following day to try again and feel you should not be liable for this cost-share because you feel the pre-procedure preparation instructions were insufficient. The Plan denied your request. The Plan says they are reviewing your concerns in a separate matter, but the claim was processed correctly, and your copayment was assessed in accordance with your contract.  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 $400 copayment for each Medicare-covered ambulatory surgical center visit.   You have been asked to pay a $400 copayment for the endoscopy. The endoscopy falls within the outpatient surgery services category and was performed in an ambulatory surgical center. 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 endoscopy procedure (43235) provided on June 1, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided on June 9, 2021.  You asked the Plan to waive the copayment for outpatient hospital observation. You say that you disagree with the charges because you were there for ten hours and nothing was really done to treat your condition. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $90 copayment for emergency services for outpatient hospital observation.   You have been asked to pay a $90 copayment for outpatient hospital observation. Outpatient hospital observation falls within the outpatient hospital observation 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 outpatient hospital observation provided on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a second pair of eyeglasses provided on April 16, 2021.  You asked the Plan to pay for a second pair of eyeglasses. The Plan denied your request. The Plan says the second pair will be member's responsibility.  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 covers one pair of eyeglasses under the vision benefit. Therefore, we decided that the Plan does not have to pay for a second pair of eyeglasses provided on April 16, 2021.