Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for wound care dressings (A6266, A4450, A6402, A6197) provided March 24, 2021.
You asked the Plan to waive the coinsurance for the wound care dressings. You say that the cost of these items should have been included in the home health service. The Plan denied your request. The Plan says the correct copayment was applied.
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% coinsurance for Durable Medical Equipment and Supplies. You have been asked to pay 20% of the Medicare allowable amount (a total of $115.04) for the wound care dressings. the wound care dressings falls within the Durable Medical Equipment 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 coinsurance for wound care dressings (A6266, A4450, A6402, A6197) provided March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 2, 2021.
You asked the Plan to pay for the laboratory services. 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. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram provided on May 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the electrocardiogram. You say that this service does not require prior authorization. The Plan denied your request. The Plan says no prior authorization was obtained.
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. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the electrocardiogram provided on May 5, 2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room services provided on April 20, 2021.
You asked the Plan to waive the copayment for the emergency room services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received emergency room services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for Emergency care. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room
services on April 20, 2021. You have been asked to pay a $90 copayment for the emergency room services. The emergency room services fall within the Emergency 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 copayment for the emergency room services provided on April 20, 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 out of network physician services provided to the enrollee on February 24, 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 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 physician services provided to the enrollee on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal cord stimulator (SCS).
You asked the Plan to pre-approve spinal cord stimulator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are only covered for certain indications. 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 spinal cord stimulator. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee is status post L4-S1 fusion. The enrollee is taking Gabapentin, Norco and Zanaflex for pain. There is no indication for a repeat SCS trial where the initial trial produced greater than 50% pain relief. The request to repeat the trial is not medically reasonable or necessary. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal cord stimulator (SCS).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on February 24, 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 physician services provided to the enrollee on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglass frames (V2020), progressive lenses (V2781) and anti-reflective coating (V2750) provided on May 5, 2021.
You asked the Plan to reimburse you for eyeglass frames, progressive lenses and anti-reflective coating. You say that your glasses had shattered, and you needed them to work. The Plan denied your request. The Plan says eyewear 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 contract says that routine eye exams and supplemental eyewear must be obtained from a provider in the Plan's vision vendor network. Services obtained from vendors outside this network are not covered. 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 eyeglass frames, progressive lenses and anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglass frames (V2020), progressive lenses (V2781) and anti-reflective coating (V2750) provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on November 12, 2020 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 November 12, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the prophylaxis (D1110) provided on April 23, 2021 by an OON provider.
You asked the Plan to pay more for the prophylaxis. You say that the documentation you got from the Plan shows that you would be responsible for a $0 copay for preventive dental services. The Plan denied your request. The Plan says the total $53.00 amount applied correctly as member liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.
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, you are responsible for the difference
between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay more for the prophylaxis (D1110) provided on April 23, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on May 6, 2021.
You asked the Plan to waive the copayment for an office visit. You say that this was your annual wellness visit
and you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were
processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10
copayment for primary care provider visits.
The medical records show that you received services beyond an annual wellness exam on May 6, 2021.
Therefore, you are responsible to pay the $10 copayment.
You have been asked to pay a $10 copayment for an office visit. An office visit falls within the
physician/practitioner services, including doctor's office visits 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 provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110) and periodic oral exam (D0120) provided on April 29, 2021, by an out-of-network provider.
You asked the Plan to pay for the cleaning and exam. You say that you believed these costs would be covered the same in-network and out-of-network and feel the Plan should pay the full cost of these services. The Plan denied your request. The Plan says they covered the dental care at the maximum allowed cost for the services; however, you are responsible for the difference between what the Plan pays for services and what the out-of-network provider bills.
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. Your contract with the Plan clearly says that you must pay a $0* copayment for a dental cleaning and a $0* copayment for a periodic oral exam. The contract also clearly states that the Plan only pays up to a certain amount for services. If you choose to see an out-of-network dentist, you may be billed for charges above what the Plan pays, even for services listed as a $0 copayment.
The provider billed the Plan a total of $144 for the two dental services you received on April 29, 2021. However, the Plan's maximum allowed cost for these two services totals $61. The Plan has paid the full $61 allowed amount. This is the amount an in-network provider would accept as full payment for this care, but out-of-network dentists do not have this agreement with the Plan and are allowed to charge you the remaining portion of the billed amount. You have been asked to pay $83 ($144 - $61 = $83). 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 pay for the dental cleaning (D1110) and periodic oral exam (D0120) provided on April 29, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on
June 4, 2021.
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that the $30.00 amount was not
paid by the Plan for this service. The Plan denied your request. The Plan says benefits for this service have
been satisfied and the frequency limitation has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, intraoral x-rays are limited to one
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220)
on June 4, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does
not have to pay for the additional intraoral periapical x-ray (D0230) provided on June 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services represented by code A0429 provided on August 18, 2020.
You asked the Plan to pay for code A0429. 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 in a situation where the beneficiary dies, whether any payment under the Medicare ambulance benefit may be made depends on the time at which the beneficiary is pronounced dead by an individual authorized by the State to make such pronouncements. We looked at the file and Medicare rules. In this case, the file shows that the enrollee's time of death pronouncement was after dispatch and before the enrollee was loaded onboard the ambulance. Medicare payment is based on the provider's/supplier's BLS base rate, no mileage or rural adjustment is reported, and the provider/supplier must use the QL modifier when submitting the claim. In this situation, the correct CPT code to bill is A0428 for non-emergency services after assessment. Therefore, we decided that the Plan does not have to pay for the ambulance services represented by code A0429 provided on August 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on
January 7, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you don't understand why
the Plan paid less than you had to for these services. The Plan denied your request. The Plan says this
copayment was charged correctly. The Plan says that the total allowed amount for the ambulance services is
$553.76, so after your copayment of $365 is subtracted, the Plan paid the remaining allowed amount of
$188.76.
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 $365
copayment for ambulance services.
You have been asked to pay a $365 copayment for the ambulance services. 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 ambulance services you received on January 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutritional therapy (97802) provided March 3, 2021.
You asked the Plan to pay for the medical nutritional therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutritional therapy (97802) provided March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 15, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a telehealth visit and you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for specialist visits, including telehealth visits. You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on January 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal injection provided on July 2, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the spinal injection. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the spinal injection provided on July 2, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81407, 81408, 81479, 81439) provided October 7, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all Cardiovascular risk assessment panels, except for the basic lipid panel for symptomatic patients with documented or suspected cardiovascular disease. We looked at the file and Medicare rules. The services at issue are not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81407, 81408, 81479, 81439) provided October 7, 2020.