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

We decided that the Plan does not have to reimburse you for eyeglass frames purchased on September 3, 2020.
You asked the Plan to reimburse you for eyeglass frames. You say that you should be covered because you resubmitted the bill. The Plan denied your request. The Plan says they did not receive an itemized bill or a receipt indicating the base lens type with the retail amount to initiate reimbursement for the lenses.
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 contract says that you receive one pair of standard eyeglasses (prescription lenses, frames, or a combination of lenses and frames) or contact lenses every calendar year. If you use a non-participating provider, you will need to pay out of pocket and submit for reimbursement. You would be reimbursed up to $90 per calendar year. We looked at the file and the Plan's rules. The records show that the Plan did not receive an itemized bill or a receipt indicating the case lens type and therefore, is not approved for reimbursement. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglass frames purchased on September 3, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit services represented by code 99213 provided on December 1, 2020.
You asked the Plan to pay for code 99213. 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. The rules say that diagnosis codes must be billed with the most precise code that most fully explains the narrative description of the symptom or diagnosis.
We looked at the file and Medicare rules. The file shows that code 99213 was billed with two unspecified diagnosis codes. The medical records indicate a bilateral diagnosis. The diagnosis codes billed in this case were not billed to the highest degree of specificity. Therefore, we decided that the Plan does not have to pay for the office visit services represented by code 99213 provided on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a fitness facility (A9270) for your 2021 Wellness Allowance.

You asked the Plan to reimburse you for a fitness facility. You say that this should be covered because you called the Plan and was advised you would be reimbursed for this. The Plan denied your request. The Plan says this benefit does not cover membership fees you pay to non-qualified health clubs or fitness facilities.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan reimburses you up to $150 per calendar year towards your cost for membership in a qualified health club or fitness facility. This benefit does not cover membership fees you pay to non-qualified health clubs or fitness facilities, including but not limited to, martial arts centers; gymnastics facilities; country clubs, sports clubs and social clubs; and for sports activities such as golf and tennis.

The Plan's rules for coverage of gym benefits have not been met. The records show that you submitted reimbursement for a ski resort which is not a covered facility. The EOC confirms that the Plan does not cover memberships fees you pay to a non-qualified health club or fitness facility. Therefore, we decided that the Plan does not have to reimburse you for a fitness facility (A9270) for your 2021 Wellness Allowance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020), progressive lenses (V2781) and anti-reflective coating (V2750) provided on December 8, 2020.
You asked the Plan to pay for eyeglass frames, progressive lenses and anti-reflective coating. You say that you are being billed by the provider and you are requesting reconsideration. The Plan denied your request. The Plan says you exhausted your benefit, and you are responsible for the remaining balance.
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 contract says that you receive a $200 allowance for the purchase of eye wear every year. The Plan contract also says that you are responsible for all costs over and above the allowance amount. We looked at the file and the Plan's rules. The records show you exhausted your $200 maximum benefit on December 8, 2020. The records also show the provider submitted a corrected claim and the Plan has paid the benefit allowance. Your total cost for your eye wear and lenses were $515. The Plan paid the $200 allowance, which leaves a remaining balance of $315 ($515 - $200 = $315). Based on this information, we decided that the Plan's rules for coverage of eyeglass frames, progressive lenses and anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020), progressive lenses (V2781) and anti-reflective coating (V2750) provided on December 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the surgical services and medical supplies provided from April 6, 2021, through May 25, 2021.

You asked the Plan to waive the copayment for the surgical services and medical supplies. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claims were processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file shows that you had eye surgery on three (3) separate dates in 2021 and were billed for cost share on the procedure. On April 6, 2021, you had surgery and were asked to pay a $300 copayment for the surgery. On April 27, 2021, you had surgery and were asked to pay a $300 copayment for the surgery. You also received medical/surgical supplies on April 27, 2021. You have been asked to pay 20% coinsurance of the allowed amount for the medical/surgical supplies. The allowed amount is $1,600. The total you owe is $1,600 ($8,000 x 20% = $1,600). On May 25, 2021, you received medical/surgical supplies. You have been asked to pay 20% coinsurance of the allowed amount for the medical/surgical supplies. The allowed amount is $819.03. The total you owe is $819.03 ($5,970 x 20% = $819.03). 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 surgical services and medical supplies provided from April 6, 2021, through May 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on January 6, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice election, this claim should be submitted to Original Medicare first.
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 medical services provided to the enrollee on January 6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided from March 1, 2021, through March 20, 2021, by an out-of-network provider.
You asked the Plan to pay for SNF care. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 SNF care provided from March 1, 2021, through March 20, 2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 36415, 80061, 84460, 84450) provided to the enrollee on October 2, 2020, by an out-of-network provider.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 (CPT code(s): 36415, 80061, 84460, 84450) provided to the enrollee on October 2, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for supervision of a nursing facility patient (99380) provided March 23, 2021.

You asked the Plan to pay for supervision of a nursing facility patient. You say that the physician rendered services in good faith. The Plan denied your request. The Plan says this service is bundled into other services.

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 CPT code 99380 is not supported for separate payment. Specifically, this code is a bundled code and payment is always included as part of another service. Based on this information, we decided that Medicare rules for coverage of supervision of a nursing facility patient have not been met. Therefore, we decided that the Plan does not have to pay for supervision of a nursing facility patient (99380) provided March 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy, 60 minutes with patient (CPT code 90837) on February 19, 2019, provided by yourself.
You asked the Plan to pay for the service. You say that you are requesting payment in the amount of $600. The Plan denied your request. The Plan says you are providing the behavioral health services to yourself; you are both the provider and the patient. The Plan states that neither Medicare nor the Health Plan cover a mental health provider student. The Plan states this is not a Medicare-qualified mental health care professional.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Medicare does not cover student in training, you are not a Medicare-qualified mental health care professional. Furthermore, Medicare prohibits a physician from making referrals for certain designated health services (DHS) payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership, investment, or compensation), unless an exception applies. Therefore, we decided that the Plan does not have to pay for psychotherapy, 60 minutes with patient (CPT code 90837) on February 19, 2019, provided by yourself.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to reduce the cost sharing for the outpatient peripheral dialysis segment stent procedure provided on April 8, 2021.
You asked the Plan to reduce the cost sharing for the outpatient procedure. You say that this service was set up by US Renal in Lytle, Texas. Because of this, you stated that you were not aware that the surgery center was out-of-network. The Plan denied your request. The Plan says that the out-of-network deductible and coinsurance was charged correctly.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. In addition, Medicare rules explicitly state that if a member gets care from an out-of-network provider when it is referred or arranged by a Plan provider, the member cannot be held responsible for more than the in-network cost sharing. The plan follows these rules. You stated that this outpatient procedure at the out-of-network facility was arranged by US Renal out of Lytle, TX. We have confirmed from the Plan's website that US Renal in Lytle, TX is a contracted provider with the Plan. The Plan has failed to address whether or not they confirmed with this plan provider if they referred the enrollee for this procedure. Because of this failure, we must agree with your assertion that the member was referred to the out-of-network ambulatory surgery center by this contracted network provider. According to Medicare rules, if members receive services from an out-of-network provider at the direction of a Plan provider, then the member can only be held responsible for what the in-network cost sharing would have been for those services. In this case, the in-network cost sharing for outpatient surgery at an ambulatory surgery center is $255. Based on Medicare rules, that is all the member can be charged for this service. Therefore, we decided that the Plan has to reduce the cost sharing for the outpatient peripheral dialysis segment stent procedure provided on April 8, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pantoprazole Sodium.
You asked the Plan to pre-approve Pantoprazole Sodium. You say that this requested drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 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 Pantoprazole Sodium.
Benefits for Pantoprazole Sodium 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on May 28, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim should be submitted to Original Medicare first for review.
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 medical services provided to the enrollee on May 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a viscosupplementation injection of Supartz to the hip.
You asked the Plan to pre-approve hip viscosupplementation. You say that the enrollee has tried physical therapy, medication, and steroids with only temporary relief and at this point everything has failed. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because treatment of trochanteric bursitis or osteoarthritis of the hip is not a covered indication for viscosupplementation.
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation may be covered under certain conditions. Viscosupplementation is not covered for intra-articular injections in joint other than the knee. We looked at the file and Medicare rules. Viscosupplementation is not covered in a joint other than the knee. Based on this information, we decided that Medicare rules for coverage of hip viscosupplementation have not been met. Therefore, we decided that the Plan does not have to pre-approve a viscosupplementation injection of Supartz to the hip.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) for tooth 9 provided June 28, 2021.
You asked the Plan to pay for the crown. You say that your crown should have lasted 5 years, and it is not your fault that it did not. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown once every five plan years. We looked at the file and Medicare rules. The Plan provided documentation showing that a crown for the same tooth was previously covered on September 12, 2018. Based on this information, we decided that the Plan's frequency limit for coverage of the crown has been exceeded. Therefore, we decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) for tooth 9 provided June 28, 2021. Your complaint about issues with customer service and being dissatisfied with the Plan 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on April 26, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 out of network services provided to the enrollee on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit and lab services you received from a family medicine doctor on May 3, 2021.
You asked the Plan to waive the deductible for the office visit and lab services. You say that the deductible shouldn't apply because this was your annual wellness visit. The Plan denied your request. The Plan says you received services outside of the scope of a wellness exam, so the deductible was applied 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 $110 deductible which applies to physician services and lab services. The medical records from this date of service show that in addition to your annual wellness visit, you were evaluated for hypothyroidism. Evaluation and work-up of a medical condition is not part of an annual wellness exam.
According to your Evidence of Coverage, the annual wellness exam only includes services to develop or update a personalized prevention plan based on your current health and risk factors. Because the physician services you received go beyond the annual wellness exam, the deductible applies. In addition, the deductible applies to any lab services as well. You had not yet met your deductible at the time of these services. Therefore, we decided that the Plan does not have to waive the deductible for the office visit and lab services you received from a family medicine doctor on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a radiology exam provided on May 24, 2021.

You asked the Plan to waive the copayment for a radiology exam. You say that you were told you would only have a $35 copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for diagnostic tests and procedures at an outpatient hospital setting. 

You have been asked to pay the allowed amount of $179.62, which is less than the $250 copayment for a radiology exam. A radiology exam 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 a radiology exam provided on May 24, 2021.