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

 We decided that the Plan does not have to pay for the hearing aids (V5261) purchased on July 21, 2021, from an out-of-network provider.  You asked the Plan to pay for out-of-network hearing aids. You say that the Plan provider tried to charge you more than your copayment amount, so you went to another provider because the base cost was cheaper. The Plan denied your request. The Plan says out-of-network hearing aids are not covered by your Plan. The Plan also says that the price you were quoted is not above the cost-share limit of the devices available, as the cost listed in the contract is per device.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are one of the approved/listed models and purchased from the Plan's specified hearing vendor.   We looked at this physician's review, the file, and the Plan's rules. The hearing aids in question were purchased from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) purchased on July 21, 2021, from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2300, V2020, V2750) purchased on August
24, 2021.
You asked the Plan to pay for the eyeglasses. You say that these services should be covered because you were
only a few days short of your two-year benefit becoming active again. The Plan denied your request. The Plan
says you previously purchased prescription eyewear on September 4, 2019. Your benefit covers up to $200
every two years for routine eyewear. This benefit is administered on a rolling calendar year since your last date
of service. The date in question is not two years from the date you last used and exhausted this benefit. The
Plan has also addressed your grievance in a separate case.
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 up to $200 toward the cost of routine contact lenses or eyewear every two years.
This benefit is administered on a rolling calendar year since your last date of service.
We looked at the file and the Plan's rules. The date in question is not two full calendar years from the date you
last used and exhausted this benefit. Based on this information, we decided that the Plan's rules for coverage of
the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses
(V2300, V2020, V2750) purchased on August 24, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided by a participating provider on May
17, 2021, to September 7, 2021.
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for these charges.
The Plan denied your request. The Plan says the benefit limit for dental services has been exhausted. The Plan
says that most of these dental services are not a covered 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 dental
services provided by a participating provider on May 17, 2021, to September 7, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for brain imaging, positron emission tomography (PET) (78608).
You asked the Plan to pay for the PET scan. You say that this appeal provides information regarding this enrollee's medical history, diagnosis and treatment plan and confirms the medical necessity and appropriateness of this prescribed treatment. The Plan denied your request. The Plan says the same study or a similar study has already been approved for the enrollee. The approved study may give the provider the details needed to treat your problem.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the PET scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the record indicates that the enrollee has suspected primary progressive aphasia. The record does not indicate a concern for dementia. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for brain imaging, positron emission tomography (PET) (78608).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 99140 provided on February 6,
2021.
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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 99140 is anesthesia complicated by emergency
conditions (specify) (List separately in addition to code for primary anesthesia procedure).
We find that CPT code 99140 is not supported in the medical record. Specifically, this code has a status
indicator of "B". This means that payment for this service is always bundled into payment for other services not
specified and no separate payment can be made. Based on this information, we decided that Medicare rules for
coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay
for the anesthesia services coded 99140 provided on February 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided August 3, 2021.
You asked the Plan to waive the copayment for the emergency ambulance transport. You say that no one discussed the enrollee's cost-share prior to the ambulance transport. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $260 copayment for each Medicare-covered one-way trip via ground ambulance. The enrollee has been asked to pay a $260 copayment for the emergency ambulance transport. The emergency ambulance transport falls within the Ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided August 3, 2021.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463) provided on August
16, 2021, by an OON provider.
You asked the Plan to pay for a hospital outpatient clinic visit. You say that the underlying focus of obtaining
an authorization is to assure the insurance carrier that the services provided are medically necessary. You also
say that clearly, this is the case in this situation. The Plan denied your request. The Plan says this provider is
not a network provider with the Plan and the services were not referred by a network provider or rendered in an
in-network facility. The Plan also says that they have also determined that these services are 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 a hospital outpatient clinic visit (G0463) provided
on August 16, 2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for a magnetic resonance imaging (MRI) provided on August 17, 2021, and August 19, 2021.  You asked the Plan to waive the copayments for an MRI. You say that you were told that the copayment was less than charged. The Plan denied your request. The Plan says the appropriate copayment was applied for both dates of 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 $275 copayment for Diagnostic radiology. On August 17, 2021, the total allowed was $222.71, since this is less than the copayment of $275 the copayment for August 17, 2021, was $222.72.  On August 19, 2021, the total allowed was $223.08, since this is less than the copayment of $275 the copayment for August 19, 2021, was $223.08. You have been asked to pay a $445.78 copayment for an MRI. An MRI falls within the Outpatient hospital 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 copayments for a magnetic resonance imaging (MRI) provided on August 17, 2021, and August 19, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravascular ultrasound (37253) provided on April 21,
2021.
You asked the Plan to pay for the intravascular ultrasound. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says the documentation does not support the
service 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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for the intravascular ultrasound. Our reviewer says that CPT
code 37253 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical
records provided do not include sufficient documentation to validate that an Intravascular ultrasound
(noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological
supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for
primary procedure) was the procedure that was performed on April 21, 2021, therefore this service cannot be
verified. The peri-anastomotic arterial segment of an AV fistula is considered part of the peripheral segment of
the AV fistula and procedures performed in it are not separately reportable.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the intravascular ultrasound have not been met. Therefore, we decided that the
Plan does not have to pay for the intravascular ultrasound (37253) provided on April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), periodic
oral evaluation - established patient (D0120), and prophylaxis - adult (D1110) provided August 4, 2021, by an
out-of-network (OON) provider.
You asked the Plan to pay for the bitewing x-rays, periodic oral exam and dental cleaning. You say that you
feel that the services should be covered. The Plan denied your request. The Plan says the provider who
rendered the service is not part of the Plan's dental vendor's network.
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 certain dental
services when they are provided by a dentist who participates in the Plan's dental vendor's network.
We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could provide the items/services at issue in this appeal. 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 bitewings - four radiographic images (D0274), periodic oral evaluation - established patient (D0120), and prophylaxis - adult (D1110) provided August 4, 2021, by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance services and an inpatient
hospital stay provided from June 17, 2021, to June 22, 2021.
You asked the Plan to waive the copayments for ambulance services and an inpatient hospital stay. You say
that you received these services due to the neglect of a physician after a hip surgery. 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 $255
copayment for ambulance services. Your contract with the Plan also clearly says that you must pay a $260
copayment for days 1-5 for inpatient hospital care.
You received ambulance services on June 17, 2021. Therefore, you are responsible to pay the $255 copayment.
You had an inpatient hospital stay from June 18, 2021, to June 22, 2021. Therefore, you are responsible to pay
a $255 copayment for days 1-4 (June 18, 2021, to June 21, 2021). The total amount you owe is: $255
(copayment) x 4 (inpatient days) = $1,040.
The total amount you owe is: $1,295.
You have been asked to pay the total copayment amount of $1,295 for ambulance services and an inpatient
hospital stay. Ambulance services fall within the ambulance services benefit category. An inpatient hospital
stay falls within the inpatient hospital care 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 ambulance services and an inpatient hospital stay provided from June 17, 2021, to June 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 10, 2021, by an 
out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
February 10, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on
August 28, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that the enrollee was
discharged in poor condition from a previous hospital stay. The Plan denied your request. The Plan says the
enrollee has 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $260 copayment for each on-way ambulance trip.
The file shows that the enrollee met their maximum out-of-pocket expenses on this trip. Therefore, the enrollee
has been asked to pay $6.42 for the ambulance transportation. Ahe ambulance transportation falls within the
Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct amount
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
ambulance transportation provided on August 28, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to hold you harmless, minus any applicable cost-sharing, for a repair of shin bone (27720, 27726) provided on February 18, 2021.

You asked the Plan to hold you harmless, minus any applicable cost-sharing, for a repair of shin bone. You say that the procedure at issue was performed by a medical doctor and that you are being balance billed. The Plan denied your request. The Plan says that rules for payment have not been met.

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. The Plan follows these rules. 

You were referred for a repair of shin bone by a contract provider. The file does not show that the Plan provided notice that a repair of shin bone would not be covered. Under Medicare rules, this means a repair of shin bone is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless, minus any applicable cost-sharing, for a repair of shin bone (27720, 27726) provided on February 18, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ophthalmological services: medical 
examination and evaluation, with initiation or continuation of diagnostic and treatment program; 
comprehensive, established patient (92014) provided June 23, 2021.

You asked the Plan to reduce the copayment for the medical eye exam. You say that you disagree with the 
copayment amount. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for each Medicare-covered eye exam.
 
You have been asked to pay a $20 copayment for the medical eye exam. The medical eye exam falls within the 
Vision 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 reduce the copayment for the ophthalmological 
services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment 
program; comprehensive, established patient (92014) provided June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on March 24, 2021, by an
out-of-network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network
care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the physician services provided on
March 24, 2021, by an out-of-network (OON) provider.