Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit and an ECG on May 6, 2021.
You asked the Plan to waive the copayment for a specialist office visit and an ECG. You say that you had an office visit with a specialist in network, which would make your copayment $40. You also ask why you are being charged $56. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for services obtained from a specialist. Your contract with the Plan also clearly says that you must pay a $20 copayment for non-radiological diagnostic services.
You have been asked to pay a $40 copayment for a specialist office visit. A specialist office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to pay $16.05, which is less than the $20 copayment for an ECG. An ECG falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit and an ECG on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for established patient home visit (99349) provided on June 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the home visit. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 established patient home visit (99349) provided on June 7, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chronic care management services provided on May 31,
2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the chronic care management services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered
benefit.
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 chronic care management services provided on
May 31, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan you had on February 4, 2021.
You asked the Plan to waive the copayment for the duplex scan. You say that you do not agree with this copayment. You said that due to your previous history, this is a normal routine service for you. You say that your previous insurance covered this service just like an office visit. 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 $110 copayment for radiological diagnostic services (except x-rays). You have been asked to pay a $110 copayment for the duplex scan. The duplex scan falls within the radiological diagnostic services (except x-rays) benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the duplex scan you had on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided on August 19, 2020.
You asked the Plan to pay for office services. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the Plan is the secondary payer for this enrollee and cannot process the claim until after the primary payer processes this claim.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has sent this bill to the enrollee's primary payer requested an Explanation of Benefits (EOB) showing the primary payer's payment of this claim. As the secondary insurer, the Plan cannot be held responsible for office services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for office services provided on August 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy (PT) services you received from May 14, 2021, to May 24, 2021.
You asked the Plan to waive the copayments for the PT services. You say that you had already met your out-of-pocket maximum so you should not have to pay copayments. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that you met your out-of-pocket maximum on the claim for date of service May 17, 2021. The Plan says that all other claims (dates of service May 14, 2021, May 20, 2021, May 21, 2021, and May 24, 2021) were processed prior to this one and the $35 copayments on those claims were applied towards meeting the out-of-pocket maximum.
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 $35 copayment per day for physical therapy services. You have been asked to pay a $35 copayment per day for the PT services. Records show that you had not yet met the out-of-pocket maximum when these claims were processed. You did meet the out-of-pocket maximum
when the last claim for these services was received (the claim for the May 17, 2021 date of service was the last one received by the Plan, so for that one, you were only charged the remaining $22.51 left on your out-of-pocket maximum.) 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 physical therapy (PT) services you received from May 14, 2021, to May 24, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the external electrocardiographic (ECG) recording services you received on April 27, 2021.
You asked the Plan to waive the copayment for the external ECG recording services. You say that you were never told that there would be a copayment for this service. 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 $75 copayment for diagnostic procedures and tests at all locations. You have been asked to pay a $75 copayment for the external ECG recording services. The external ECG recording services fall within the diagnostic procedures and tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the external electrocardiographic (ECG) recording services you received on April 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trifecta allograft and bone marrow aspirate.
You asked the Plan to pre-approve Trifecta allograft and bone marrow aspirate. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 pre-approve Trifecta allograft and bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Trifecta allograft and bone marrow aspirate remains experimental in spine surgery. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Trifecta allograft and bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve Trifecta allograft and bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for anesthesia.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for anesthesia.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on April 29, 2021 by a licensed marriage family therapy (LMFT).
You asked the Plan to pay for the LMFT services. You say that you are new to Medicare and were not aware this provider was not able to be paid. You now have a large balance that you cannot afford and feel that payment should be made. The Plan denied your request. The Plan says the type of provider is not able to be paid by Medicare for these services.
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 the psychotherapy services provided on April 29, 2021 by a licensed marriage family therapy (LMFT).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy services (90837) provided on May 6, 2021 to May 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you are new to Medicare benefits and was unaware that psychotherapy could not be provided by a licensed marriage and family therapist. You are not able to pay out of pocket for the services. The Plan denied your request. The Plan says service received from ineligible provider. The provider is a marriage and family therapist (LMFT). A LMFT is not eligible to bill Medicare for mental health services.
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 health plan contract says that your provider may need to obtain prior authorization for outpatient mental health care. You can find this information on page 4-35 of the Plan's Evidence of Coverage. 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 individual psychotherapy services (90837) provided on May 6, 2021 to May 11, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided on March 31, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the billed service was not urgent, emergent or 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 office visit (99214) provided on March 31, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on April 15, 2021.
You asked the Plan to waive the copayment for arthrocentesis. You say that you thought that the injections would be fully covered. 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 $275 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received arthrocentesis at an outpatient hospital facility on April 15, 2021. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $260.28, which is less than the $275 copayment. You have been asked to pay $260.28 for arthrocentesis. Arthrocentesis falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the administration of the COVID vaccine provided on April 8, 2021.
You asked the Plan to pay for the COVID vaccine administration. You say that this should be covered as the Plan covers this vaccine. The Plan denied your request. The Plan says payment must be requested from the Original Medicare contractor for 2020 and 2021.
The Plan must follow Medicare rules. Medicare rules say that providers are instructed to send claims for the administration of COVID vaccines to Original Medicare. Though this vaccine is covered, payment is not made by this Medicare Advantage plan. Therefore, we decided that the Plan does not have to pay for the administration of the COVID vaccine provided on April 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary assessment for cardiac conditions testing provided on November 30, 2020.
You asked the Plan to pay for the hereditary assessment for cardiac conditions testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. There is no documentation in the case file that supports that the hereditary assessment for cardiac conditions testing at issue in this appeal was not requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary assessment for cardiac conditions testing provided on November 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the injection procedures you had at an
ophthalmologist's office on January 22, 2021, and March 12, 2021.
You asked the Plan to waive the copayments for the injection procedures. You say that you should not have to
pay these copayments. You say that you get these injections every six weeks, and that on every third
appointment, you also receive a full eye exam. You stated that because you didn't receive a full eye exam on
the dates of service in question (just the injections), that you should not have to pay the copayments. The Plan
denied your request. The Plan says you were charged these copayments 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 $40
copayment for medical care or surgery services in a specialist's office.
You have been asked to pay a $40 copayment for the injection procedures. This copayment applies regardless
of the extent of services you receive in the doctor's office. There is no requirement that you get a full eye exam
in order for the copayment to 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
procedures you had at an ophthalmologist's office on January 22, 2021, and March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lenses (V2599) provided on November 13, 2020.
You asked the Plan to pay for contact lenses. You say that your contact lenses have been partially covered in the past and now that you have a new plan it is not covered. You also say you received a better price with the out-of-network provider. The Plan denied your request. The Plan says contact lenses will only be covered when they are received from a provider in the specified vision network.
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 received from a provider who participates in the Plan's specified vision network. We looked at the file and the Plan's rules. The records show that the service at issue was provided by an out-of-network provider. This service is not covered by the Plan when provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for contact lenses (V2599) provided on November 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on April 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab test. You say that this testing is covered by Medicare and should be reimbursed by the Plan. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.
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 laboratory testing provided on April 7, 2021 by an out-of-network (OON) provider.