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

We decided that the Plan does not have to pay for the lenses (V2200), ophthalmological medical examination and evaluation (92004), and the eye refraction (92015) rendered by the out-of-network (OON) provider on April 28, 2021.
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the items/services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the items/services 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 lenses (V2200), ophthalmological medical examination and evaluation (92004), and the eye refraction (92015) rendered by the out-of-network (OON) provider on April 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan you received on March 17, 2021.

You asked the Plan to waive the copayment for the duplex scan. You say that you do not understand why the Plan didn't pay on the claim. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($140.81) is less than your copayment obligation, you are responsible for the full allowed 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 $155 copayment for radiological diagnostic services.

You have been asked to pay a $155 copayment for the duplex scan. The duplex scan falls within the radiological diagnostic 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 copayment for the duplex scan you received on March 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lab services provided on April 20, 2021.

You asked the Plan to waive the deductible for lab services. You say that you disagree with the denial of
charges because the labs were taken as part of your annual wellness exam. 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. Your
contract with the Plan says that there is a $550 deductible which applies to outpatient diagnostic tests and
therapeutic services and supplies.

You received lab services on April 20, 2021. Lab services are not included in annual wellness exams. The
record shows that you had only paid $91.89 toward the $550 deductible prior to receiving the services.
Therefore, you are responsible to pay the allowed amount of $29.13.

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $550 deductible which applies to outpatient diagnostic tests and
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time
lab services was received on April 20, 2021. Therefore, we decided that the Plan does not have to waive the
deductible for lab services provided on April 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a physical therapy evaluation to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve a physical therapy evaluation. You say that this provider is close to your home and all other places you have tried have turned you away. The Plan denied your request. The Plan says the services are not emergent/urgent and are available within the network.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a physical therapy evaluation to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a vacuum erection device (L7900) provided on March 17,
2021.

You asked the Plan to pay for a vacuum erection device. You say that your doctor prescribed the device at issue
for you after prostate surgery. The Plan denied your request. The Plan says rules for payment have not been
met because the item at issue is statutorily non-covered.

The Plan must follow Medicare rules. Medicare rules say that vacuum erection devices are statutorily noncovered.
Based on this information, we decided that Medicare rules for coverage of a vacuum erection device
have not been met. Therefore, we decided that the Plan does not have to pay for a vacuum erection device
(L7900) provided on March 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency
transport, (A0428, A0425) provided on April 24, 2021.

You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that the
member was treated for edema and hemorrhage and she was taken from the hospital emergency department and
transported to a skilled nursing facility. You say the member required transport via ambulance due to severe
muscular weakness, inability to self-ambulate, and risk of falling from a wheelchair. The Plan denied your
request. The Plan says the member is able to sit and was placed in a chair upon arrival. She is not bed-bound
and can be transported by alternate means of transportation such as a wheelchair van.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.

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 Ambulance service, basic life support, non-emergency
transport. Our reviewer says that ambulance service, basic life support, non-emergency transport is not medically
necessary. Our physician reviewer found the documentation does not support that other means of transport
(such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this
enrollee. The documentation does not support that the enrollee needed the expertise, services and lifesaving and
life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The
documentation does not support that the ambulance transport on April 24, 2021 was medically reasonable and
necessary for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been
met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency
transport, (A0428, A0425) provided on April 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 15, 2020.

You asked the Plan to pay for out of network services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you 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 must 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 on April 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on October 17, 2019.
You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says no 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 physical therapy. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physical therapy provided on October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ostomy supplies you received from January 4, 2021, to January 13, 2021.

You asked the Plan to waive the copayments for the ostomy supplies. You say that you were enrolled in the plan without your permission and you used to be in a plan that had no copayments. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that for dates of service January 5, 2021, to January 13, 2021, the allowed amount for each date ($13.14) is less than your copayment obligation, so you're responsible for the full allowed amount for those items.

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 medical supplies.

You have been asked to pay a $50 copayment for the ostomy supplies. The ostomy supplies fall within the medical 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 copayments for ostomy supplies you received from January 4, 2021, to January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for tart cherry extract capsules provided on February 21, 2021.
You asked the Plan to pay for tart cherry extract capsules. You say that your doctor prescribed tart cherry extract capsules for treatment of your arthritis. The Plan denied your request. The Plan says tart cherry extract capsules not a covered item under the Pick Your Perks program.
The Plan contract covers a supplemental benefit under the Pick Your Perks program. We looked at the file and the Plan's rules. The file shows that the Plan does not cover tart cherry extract capsules under the supplemental benefit. Therefore, we decided that the Plan does not have to pay for tart cherry extract capsules provided on February 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a pulp vitality test (D0460), consultation (D9310), endodontic therapy (D3320), and dental X-ray imaging (D0220, D0230) provided on March 31, 2021.

You asked the Plan to pay for a pulp vitality test, consultation, endodontic therapy, and dental X-ray imaging. You say that the services at issue were a medical necessity for you. The Plan denied your request. The Plan says rules for payment have not been met.

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 a pulp vitality test (D0460), consultation (D9310), endodontic therapy (D3320), and dental X-ray imaging (D0220, D0230) provided on March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81317, 81407, 81408, 81479, 81295, and 81298) provided on September 3, 2020.
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. We looked at the file, the Plan's contract and Medicare rules. If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel. If the laboratory assays genes in serial, then the laboratory must submit claims for genes individually. The order by the treating clinician must reflect whether the treating clinician is ordering a panel or single genes, and additionally, the patient's medical record must reflect that the service billed was reasonable and necessary. When more than two codes from this list are submitted for the same beneficiary on the same date of service, the claims processing system will reject every code submitted after the first two services. However, if a lab runs more than two distinct procedural services from this list on a single date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it is a distinct procedural service. In this case, the medical records provided do not confirm that the labs were billed correctly. Therefore, we decided that the Plan does not have to pay for the laboratory services (81317, 81407, 81408, 81479, 81295, and 81298) provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ophthalmology visit and the gonioscopy you received on April 20, 2021.

You asked the Plan to waive the copayments for the ophthalmology visit and gonioscopy. You say that you do not believe two separate copayments should be charged because you believe the gonioscopy should be considered part of the visit. 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 $45 copayment for specialist visits. 

You have been asked to pay a $45 copayment for the ophthalmology visit (procedure code 99213) and a $25 copayment for the gonioscopy (procedure code 92020). Medicare uses what is called the National Correct Coding Initiative (NCCI) to determine which codes are separately payable when billed together. NCCI edits show that procedure codes 99213 and 92020 are separately billable. Code 92020 is not considered part of 99213, so a separate copayment can apply. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the ophthalmology visit and the gonioscopy you received on April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided March 8, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the periodontal scaling and root planing. You say that you received a brochure listing this provider as in-network. The Plan denied your request. The Plan says the provider is not in the Plan's network and therefore the services are not covered. The Plan also says they cannot locate any brochure listing the provider as in-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 the periodontal scaling and root planing when the services are provided in-network. We looked at the file and Medicare rules. 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 cover the requested service. Based on this information, we decided that the Plan's rules for coverage of the periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided March 8, 2021, by an out-of-network (OON) provider.
Your complaint about potentially receiving a brochure from the Plan which provided incorrect information about network providers 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network outpatient mental health care provided to the enrollee from April 2, 2021, to June 15, 2021.

You asked the Plan to pay for out of network services. You say that these services should be covered by the Plan. 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 outpatient mental health care provided to the enrollee from April 2, 2021, to June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic imaging of the retina (92134) provided on March 11, 2021.
You asked the Plan to waive the copayment for imaging of the retina. You say that you have never paid more than your specialist office visit copayment for a visit with your ophthalmologist. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $47.26 copayment for imaging of the retina. The EOC confirms that there is a separate cost share in addition to the specialist office visit copayment. The EOC also confirms that $50 is the required copayment for this service. You have been asked to pay a copayment of $47.26, which is less than the Plan's contracted amount. Imaging of the retina 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 diagnostic imaging of the retina (92134) provided on March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a gym membership for the 2020 benefit allowance.
You asked the Plan to reimburse you for a gym membership. You say that you pay for your membership for the year. You also say the Plan should pay the claim and not give you the run around. The Plan denied your request. The Plan says the request for reimbursement was not sent in during the contractual obligation.
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 contract says that the Plan provides an annual reimbursement allowance of $150 towards paid memberships at non-participating fitness clubs and exercise centers. The Plan contract also says that payment requests should be submitted after that month has passed, but within 90 days of the end of the calendar year. The Plan's rules for coverage of gym benefits have not been met because the records show that you submitted a request for reimbursement on June 15, 2021. The EOC confirms that reimbursement should be submitted after that month has passed but within 90 days of the end of the calendar year. Therefore, we decided that the Plan does not have to reimburse you for a gym membership for the 2020 benefit allowance.