Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 4, 2021.
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 the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was 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 laboratory services rendered on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on December 29, 2020.

You asked the Plan to pay for an eye refraction. You say that you would like the Plan to pay for this service. The Plan denied your request. The Plan says the service at issue is not a covered benefit. Eye refraction is only covered by the Plan when it is performed as part of a routine screening by a participating provider.

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 it is performed as a routine screening by a participating provider. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Specifically, eye refraction is only covered by the Plan when it is performed as part of a routine screening by a participating provider. This service was performed for medical vision purposes, and therefore is not a covered benefit. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on December 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) provided on November 2, 2020.

You asked the Plan to pay for the incisional biopsy of oral tissue. You say that this service should be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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. Therefore, we decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) provided on November 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound provided on November 30, 2020 by an out of network provider.

You asked the Plan to pay for the abdominal ultrasound (76705). You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound provided on November 30, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on February 18, 2021 under the Pick Your Perks Reimbursement Program.

You asked the Plan to pay for the physical therapy under the Pick Your Perks Reimbursement Program. The Plan denied your request. The Plan says that physical therapy is not a covered benefit under the Pick Your Perks Reimbursement Program.

We looked at the file and the Plan's rules. The file shows that the physical therapy is not covered under the Plan's supplemental benefit. Therefore, we decided that the Plan does not have to pay for physical therapy provided on February 18, 2021 under the Pick Your Perks Reimbursement Program.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient diagnostic services coded as 45380, 43239, 99153 and G0500 provided on December 9, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the diagnostic services. You say that your clinical documentation is clear and demonstrates medical necessity. Kindly process the claim towards payment. 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 the outpatient diagnostic services coded as 45380, 43239, 99153 and G0500 provided on December 9, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the ambulance transportation service (A0428) provided on December 27, 2020.

You asked the Plan to waive the co-payment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the co-payment has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 co-payment for each Medicare-covered one-way trip by ground transportation.

You have been asked to pay a $225 co-payment for the Medicare-covered one-way ground ambulance trip. 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 co-payment for the ambulance transportation service (A0428) provided on December 27, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided December 10, 2020.

You asked the Plan to waive the copayment for the emergency visit. You say that you don't think this is a valid charge because you did not stay in the emergency room. The Plan denied your request. The Plan says this claim was processed and the correct copayment was 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 $100 per visit for Emergency care. 

You have been asked to pay $100 per visit for the emergency visit. the emergency visit falls 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 visit provided December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and smear provided on January 11, 2021 by an out of network provider.

You asked the Plan to pay for the office visit and smear. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the office visit and smear provided on January 11, 2021 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the resin composite for tooth # 2 provided on January 4, 2021.

You asked the Plan to pay the full amount for the dental service. You say that page 131 of the 2021 Evidence of Coverage book shows $0 payment for minor restorative services, fillings and crown repair. You say that you feel that the $46 charge should be reversed. You also say that your dentist only does resin composite. The Plan denied your request. The Plan says a resin-based composite restoration on a posterior tooth is not covered. The Plan says this service will be paid at the rate of an amalgam restoration. The Plan also says that you are responsible for the difference.

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 and fillings are listed as covered, coverage for posterior composite restorations is based on the allowed amount for amalgam fillings. The record shows that the allowed amount for an amalgam is $125 and the billed amount for resin composite is $171. $171-$125=$46. Therefore, we decided that the Plan does not have to pay more for the resin composite for tooth # 2 provided on January 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient post-stabilization services provided November 15, 2020 to November 16, 2020.

You asked the Plan to pay for the post-stabilization services. You say that you feel that the denial of the inpatient hospital days, during which time, supportive care and conservative management were provided to the enrollee is unjust, and request approval and reimbursement for care provided. The Plan denied your request. The Plan says the enrollee was clinically stable for transfer in-plan beginning 11/15/20 at 11:42. Inpatient services on or after 11/15/20 at 11:42 are being denied as unauthorized post-stabilization care.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the post-stabilization services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found given that the medical records support that the enrollee was stable for transfer on 11/15/20, that is the date when the transfer should have been initiated. There is no documentation that the transfer was attempted and there was no bed available. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the post-stabilization services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient post-stabilization services provided November 15, 2020 to November 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the ambulance transportation service (A0428) provided on January 12, 2021.

You asked the Plan to waive the co-payment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the co-payment has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that he must pay a $150 co-payment per one-way ground ambulance trip.

The enrollee has been asked to pay a $150 co-payment for the one-way ground ambulance trip provided. This means that the enrollee has been asked to pay the correct amount based on his contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when he enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for the ambulance transportation service (A0428) provided on January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services (88307) provided October 17, 2019.

You asked the Plan to pay for the pathology services. You say that the claim was filed timely. The Plan denied your request. The Plan says a correct claim was received untimely.

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 pathology services was not filed until November 2, 2020. 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 pathology services (88307) provided October 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781 x2), and UV lens (V2755) received on November 21, 2020.

You asked the Plan to pay for progressive lenses, and UV lens. You say that you do not understand why the Plan will not cover the services. The Plan denied your request. The Plan says the services at issue are 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 progressive lenses, and UV lens have not been met. Specifically, on the date of service, the items at issue were not a covered benefit. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781 x2), and UV lens (V2755) received on November 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 21, 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.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal was 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 laboratory services provided on December 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on December 15, 2020.

You asked the Plan to pay for the dental item. You say that you got a dental mouth guard in December 2019. You say that you were reimbursed for this item. You say that you received another dental mouth guard in December 2020. You also say that your plan changed without any notice. The Plan denied your request. The Plan says occlusal guard is not listed as a covered service.

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 the occlusal guard (D9944) provided on December 15, 2020.

Your complaint about your plan switching without notice 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on January 7, 2021.

You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says an eye refraction is not a covered benefit for a medical exam.

The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.

We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services rendered from November 2, 2020 to December 23, 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 the services are not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. The file shows that the provider billed procedure codes 97012 (mechanical traction therapy), 97110 (therapeutic exercises), and 97112 (neuromuscular re-education). Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered from November 2, 2020 to December 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services.

You asked the Plan to pay for inpatient services. You say that the hospital will not release the enrollee unless she has 24/7 care. The Plan denied your request. The Plan says the care could be provided in an observation level of care.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 inpatient services. Our physician reviewer found that it is not reasonable to expect that two midnights of inpatient level care is medically necessary. The enrollee is essentially being held to await placement, not to receive medical services. As such, inpatient hospitalization is not medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on September 28, 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 95887 is not covered.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 95887 is 1. You billed 2 units of this code, exceeding the MUE. 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 testing services rendered on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the specialist office visit provided on December 22, 2020.

You asked the Plan to waive the co-payment for the specialist office visit. You say that you do not feel you owe a co-payment since you only asked a question, and they only took your blood pressure The Plan denied your request. The Plan says you were charged this co-payment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 co-payment for Physician Specialist Services.

You have been asked to pay a $45 co-payment for the specialist office visit. The specialist office visit falls within the Physician Specialist 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 co-payment for the specialist office visit provided on December 22, 2020.