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

We decided that the Plan does not have to pay for a dental resin-based composite (code D2391) provided on April 1, 2021.
You asked the Plan to pay for resin-based composite. You say that you were advised that the Plan does cover this procedure. The Plan denied your request. The Plan says the denial of payment for this service is correct, because you have not enrolled in the optional Platinum Dental Rider and therefore this service is not covered by the Plan.
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 because you were not enrolled in the Plan's optional Platinum Dental Rider. Therefore, we decided that the Plan does not have to pay for a dental resin-based composite (code D2391) provided on April 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for digital breast tomosynthesis (77062) provided on September 28, 2020.
You asked the Plan to pay for digital breast tomosynthesis. You say that this is documented in the records. The Plan denied your request. The Plan says this was not billed with a valid code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 77062 is not supported in the medical record. Specifically, this code has a status
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for digital breast tomosynthesis (77062) provided on September 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81226, 81227, 81231, 81240, 81241, 81291, 81230, 84439, 84443, 82728, 82977, 83036, 83655, 83825, 82306, 82495, 80061 and 81225 provided on July 14, 2020.
You asked the Plan to pay for the laboratory 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 supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 81226, 81227, 81231, 81240, 81241, 81291, 81230, 84439, 84443, 82728, 82977, 83036, 83655, 83825, 82306, 82495, 80061 and 81225 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a
laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates
that the specimen was obtained in an office setting place of service 11. Based on this information, we decided
that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the
Plan does not have to pay for the laboratory services coded 81226, 81227, 81231, 81240, 81241, 81291, 81230,
84439, 84443, 82728, 82977, 83036, 83655, 83825, 82306, 82495, 80061 and 81225 provided on July 14,
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on October 1, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 27487 is not supported.
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 27487 is revision of total knee arthroplasty, with or
without allograft; femoral and entire tibial component.
We find that CPT code 27487 is not supported in the medical record. Specifically, there is no documentation of
a total knee arthroplasty revision with femoral and entire tibial component.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the surgical services rendered on October 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergent ambulance
transport (A0428) provided on February 20, 2020.
You asked the Plan to pay for the ground mileage and non-emergent ambulance transport. The Plan denied
your request. The Plan says this claim was received on April 8, 2021 which is past the allowed 12 month
timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the ground mileage and non-emergent ambulance transport was not filed
until April 8, 2021. This means that more than one calendar year from the date of service had passed before a
claim was filed. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and
non-emergent ambulance transport (A0428) provided on February 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the exercise swimming pool purchased on July 1, 2020.
You asked the Plan to provide reimbursement for the exercise pool. You say that you feel that this should be reimbursed because your doctor prescribed this due to your medical conditions. The Plan denied your request. The Plan says this is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to provide reimbursement for the exercise swimming pool purchased on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the sphere bifocal and deluxe frames provided on March 15, 2021.
You asked the Plan to pay more for the sphere bifocal and deluxe frames. You say that you dutifully looked up the coverage and purchased eyeglasses at your physician's office. You say that these are included in the coverage that you pay for and you are appealing the total amount of $350. The Plan denied your request. The Plan says the vision services processed correctly applying $100 toward your benefits.
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 $100 toward the purchase of frames and lenses. We looked at the file and the Plan's rules. The Plan paid $100 toward the purchase of the sphere bifocal and deluxe frames. Based on this information, we decided that the Plan's rules for additional coverage of the sphere bifocal and deluxe frames have not been met. Therefore, we decided that the Plan does not have to pay more for the sphere bifocal and deluxe frames provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for established patient custodial care facility, group care, or assisted living visit (99335) provided on March 12, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for established patient custodial care facility, group care, or assisted living visit. You say that this request is medically reasonable and necessary. The Plan denied your request. The Plan says prior authorization was not obtained before these services were rendered by an OON provider.
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 custodial care facility, group care, or assisted living visit (99335) provided on March 12, 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 October 18, 2019.
You asked the Plan to pay for the office visit. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says this claim was submitted past the allowed 12 month time frame.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the office visit was not filed until March 11, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the office visit (99214) provided on October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or established patient (D0180) provided March 23, 2021.
You asked the Plan to pay for the comprehensive periodontal exam. You say that you were referred this provider by your regular dentist and confirmed with the Plan that the provider is in network. You believe the Plan should cover the service. The Plan denied your request. The Plan says you are covered for one dental exam per year which the Plan has already covered and therefore this dental exam is not covered.
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 diagnostic/preventative evaluations once per calendar year.
We looked at the file and Medicare rules. The Plan provided documentation showing that a periodic oral evaluation was previously covered on February 24, 2021. Based on this information, we determined that the Plan's frequency limit for diagnostic/preventative dental exams has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or established patient (D0180) provided March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the health club membership (S9970).
You asked the Plan to pay an additional amount for the health club membership. You say that you would like to receive more reimbursement for your health club membership. The Plan denied your request. The Plan says the maximum amount of reimbursement for the health club membership has been provided to you.
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 can receive up to $300 each calendar year in reimbursement for Health and Wellness programs. You submitted a request for reimbursement to the Plan in the amount of $101.88. $12.90 of this amount was refunded to you. The Plan agreed to provide reimbursement for the health club membership up to $88.98. The refunded amount of $12.90 is not eligible for reimbursement. This means that you have been reimbursed 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 an additional amount for the health club membership (S9970).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular risk analysis (81404) provided on February 1, 2021.
You asked the Plan to pay for hereditary cardiovascular risk analysis. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of hereditary cardiovascular risk analysis have not been met. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular risk analysis (81404) provided on February 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for transthoracic echocardiography (93306) provided February 17, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you feel that you should not be charged a copayment. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $110 copayment for Medicare covered diagnostic radiology services for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay $110 copayment for Medicare covered diagnostic radiology services for the diagnostic service. the diagnostic service 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 transthoracic echocardiography (93306) provided February 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating facility
on March 9, 2021.
You asked the Plan to waive the copayment for an x-ray. You say that you do not agree with this. You say that
you do not agree with the Plan paying $0. The Plan denied your request. The Plan says the correct copayment
has been 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 $110
copayment for outpatient diagnostic tests/in-network/x-rays.
You have been asked to pay a $74.55 which is less than your copayment amount of $110 for an x-ray. An x-ray
falls within the outpatient diagnostic tests/in-network/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 an x-ray provided by a participating facility on March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis and intraoral x-rays provided on March 31, 2021.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis and intraoral x-rays. You say that you saw the same dentist you had seen before and payment was made. You say that you were never informed the provider was no longer covered and the services should be 100% covered. The Plan denied your request. The Plan says services performed by an out-of-network provider are not covered.
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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis and intraoral x-rays provided on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 5, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that you were not aware of the frequency limitation for this service. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 3 Plan years.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on December 12, 2019. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that prior to the services being rendered the plan was contacted. The procedure was done with the full expectation that the Plan would provide payment as if the pre-authorization has been given. The Plan denied your request. The Plan says items re used for a preventative service or function are excluded from coverage.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation provided on March 8, 2021.
You asked the Plan to pay for the limited oral evaluation. You say that you verified the dentist was in-network before scheduling the appointment and you confirmed insurance would cover the services in-network. You say that the denial should be corrected. The Plan denied your request. The Plan says the claims reprocessed to apply your in-network benefits.
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 limited oral evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation provided on March 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV infusion of Clindamycin provided from July 27, 2020,
to July 31, 2020 by an OON provider.
You asked the Plan to pay for the IV infusion of Clindamycin. You say that these services were medically
necessary. The Plan denied your request. The Plan says the information provided did not show that the service
provided, was for an emergency, that you were referred by an in-network doctor, and that the service was not
available within the Plan's 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 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 IV infusion of Clindamycin provided from July 27, 2020, to July 31, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for anti-reflective coating (V2750) provided on February 26, 2021.
You asked the Plan to pay for anti-reflective coating. You say that you want the Plan to pay for this service. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of anti-reflective coating have not been met. Specifically, anti-reflective coating is not a covered benefit. Therefore, we decided that the Plan does not have to pay for anti-reflective coating (V2750) provided on February 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from January 21 through January 27, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you have only had to pay $250 for surgeries before. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $280 copayment per day for days 1 - 6 for Inpatient Hospital Care.
You have been asked to pay a $1,680 copayment ($280 per day for days 1 - 6) for the inpatient hospital stay. The 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 copayment for the inpatient hospital stay from January 21 through January 27, 2021.