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

 We decided that the Plan does not have to pay for the laboratory services (82542, 80307, 84228, G0480) rendered by the out-of-network (OON) provider on July 27, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (82542, 80307, 84228, G0480) rendered by the out-of-network (OON) provider on July 27, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology procedures provided on April 28, 2021.  You asked the Plan to pay for radiology procedures. The Plan denied your request. The Plan says Medicare guidance says once a managed care enrollee has elected hospice, all his or her Medicare benefits revert to fee-for-service, though the enrollee still remains on managed care for any additional benefits provided by his or her managed care plan, such as dental or vision coverage. 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. Upon discharge orrevocation, fee-for-service Medicare continues to cover the beneficiary through the end of the month when the beneficiary revokes or is discharged from hospice alive.  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 radiology procedures provided on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic, prophylactic, or diagnostic injection (96372), the office visit (99213), and the methylprednisolone acetate injection (J1040) rendered by the out-of-network (OON) provider on August 9, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the therapeutic, prophylactic, or diagnostic injection (96372), the office visit (99213), and the methylprednisolone acetate injection (J1040) rendered by the out-of-network (OON) provider on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on July 14, 2021.
You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says you do not have out-of-network vision/eyewear benefits.
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 provided by the Plan's vision provider. We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plan's
vision provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the primary care office visit you had on June 23, 2021.
You asked the Plan to waive the copayment for the primary care office visit. You say that this was an annual wellness visit, so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $20 copayment for primary care visits.
You have been asked to pay a $20 copayment for the primary care office visit. According to your Evidence of Coverage, an Annual Wellness Visit only includes services to develop or update a personalized prevention plan based on your current health and risk factors. We looked at the medical records from this visit to see what services you received. The records explicitly state that during your visit you were following up on prediabetes, hypertension and hyperlipidemia. You were advised to get an A1C lab test. You were also given a Tetanus vaccine. These services are above and beyond an Annual Wellness visit, so an office visit copayment can 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 copayment for the primary care office visit you had on June 23, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the eye refraction services (92015) provided on July 15, 2021.  You asked the Plan to pay for code 92015. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan denied payment for the eye refraction services (92015) stating that you have exceeded the maximum benefit limit and that refraction services are not separately payable. However, the Plan has not provided any claims or medical records showing that you have exhausted the routine eye exam with refraction services benefit. Furthermore, the Plan's contract does not state that these services cannot be billed separately. We find that the Plan has not provided enough evidence to support their reasoning for denial of payment. Therefore, we decided that the Plan has to pay for the eye refraction services (92015) provided on July 15, 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for inpatient hospital services you received from June 22, 2021, to June 25, 2021.  You asked the Plan to reduce the copayment for the inpatient hospital services. You say that you were only in the hospital for two nights, so you were charged incorrectly. The Plan denied your request. The Plan says you were charged this copayment 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 $175 copayment per day for days 1-5 for inpatient hospital services.   Records show that you were admitted on June 22, 2021, and discharged on June 25, 2021.  This is a total of three days.  You were charged a $175 copayment per day, for a total of $525. 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 inpatient hospital services you received from June 22, 2021, to June 25, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on August 3, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that the only reason you went to the ER is because your doctor told you too. You said that you were in and out within two hours because you were just tired and dehydrated. The Plan denied your request. The Plan says you were charged this copayment 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 $90 copayment per visit for emergency care. You have been asked to pay a $90 copayment per visit for the ER visit. This copayment applies regardless of the reason for the ER visit. 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 emergency room (ER) visit you had on August 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on August 4, 2021.  You asked the Plan to pay for the ambulance treatment without transport. You say that these services were necessary, and you thought ambulance treatment was covered by your insurance. You say your vital signs were fine and you did not need to go to the hospital and did not realize the ambulance services would not be covered without transportation. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. When there is no transportation provided, 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 August 4, 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 the ambulance response and treatment without transport (A0998) provided on August 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services provided on April 12, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that when you call 911 you get whoever will be sent.  You stated that you didn't expect that this service wasn't covered because it was out-of-network. The Plan denied your request. The Plan says this service was not denied because it was out-of-network.  Rather, the enrollee was assessed the appropriate cost sharing 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment for ambulance services.   The enrollee has been asked to pay a $225 copayment for the ambulance services. 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 copayment for ambulance services provided on April 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy evaluation provided on December 19, 2019.  You asked the Plan to pay for the physical therapy evaluation. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says this service is not supported without the required documentation.    The Plan must follow Medicare rules. the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy evaluation have not been met. Specifically, medical records were not submitted to confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the physical therapy evaluation provided on December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a walker purchased on May 24, 2021.   You asked the Plan to pay for this equipment. You say that the Plan should pay for this walker. The Plan denied your request. The Plan says this provider is not a Medicare eligible provider.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who is not a Medicare eligible provider. This includes commercial retailers or online vendors. The Plan contract says that durable medical equipment may require prior authorization. Walkers would be the type of equipment that requires prior authorization. This walker was purchased without prior authorization from a commercial retailer who is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for a walker purchased on May 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the aflibercept injection provided on July 29, 2021.  You asked the Plan to waive the coinsurance for the aflibercept injection. You say that you will need medication for your eyes every month. You say that you are on a fixed income and will need help paying the copayment. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B chemotherapy prescription drugs and non-chemotherapy prescription drugs.    You have been asked to pay $366.56, which is 20% of the allowed amount for the aflibercept injection. The allowed amount is $1,832.82 (20% x $1,832.82 = $366.56). The aflibercept injection 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 coinsurance for the aflibercept injection provided on July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81546) rendered by the out-of-network (OON) provider on June 22, 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 (81546) rendered by the out-of-network (OON) provider on June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), intraoral x-ray (D0220), unspecified preventative procedure (D1999) and root canal (D3330) provided on June 24, 2020, by an out-of-network endodontist.  You asked the Plan to pay for the out-of-network dental care. You say that you were not aware that this provider was out-of-network, and these services were urgent. The Plan denied your request. The Plan says supplemental dental care must be received from a participating general dentist. Services received from out-of-network providers or dental specialists (such as an endodontist, periodontist or oral surgeon) 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. The Plan requires supplemental dental care to be performed by a participating general dentist. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received out-of-network or from dental specialists are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), intraoral x-ray (D0220), unspecified preventative procedure (D1999) and root canal (D3330) provided on June 24, 2020, by an out-of-network endodontist.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for out-of-network physical therapy provided on July 23, 2021.
You asked the Plan to pay for out-of-network physical therapy. You say that the office, individual provider as well as the referring provider are participating providers with Medicare. You say that the physical therapist treated her with the medical care required and the services should be approved for payment. The Plan denied your request. The Plan says out-of-network services were not authorized. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 out-of-network physical therapy provided on July 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services (76705) provided on July 19, 2021.
You asked the Plan to pay for code 76705. 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. In this case, we have confirmed that code 76705
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the ultrasound services (76705) provided on July 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve a power seat elevation system. You say that the requested item is necessary.
The Plan denied your request. The Plan says the item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and
power standing feature (E2301) are non-covered because they are not primarily medical in nature.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not
have to pre-approve a power seat elevation system.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory service (81479) rendered by the out-of-network (OON) provider on December 23, 2020.  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 (81479) rendered by the out-of-network (OON) provider on December 23, 2020.