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

We decided that the Plan does not have to pay an additional amount for the limited oral evaluation - problem focused (D0140), the intraoral - periapical each additional radiographic image (D0230), and the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) received December 23, 2020 from the out-of-network provider.
You asked the Plan to pay an additional amount for the dental services. You say that you were told by the Plan's representative that the claim would be fully covered. The Plan denied your request. The Plan says you may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider.
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 payment is in excess of that which is covered under this benefit. The Plan agreed to pay 100% of the cost, up to the maximum allowable fee rate for in-network providers. According to your contract, you may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider. Therefore, we decided that the Plan does not have to pay an additional amount for the limited oral evaluation - problem focused (D0140), the intraoral - periapical each additional radiographic image (D0230), and the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) received December 23, 2020 from the out-of-network provider.
Your complaint about being informed by the Plan's representative that the claim would be fully covered 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 10, 2021 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 physician services provided on February 10, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit provided on October 21, 2020.
You asked the Plan to waive the copayment for an outpatient hospital facility visit. You say that this has been settled to a $50 copayment. 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 $465 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay the allowed amount of $134.85, which is less than the $465 copayment for an outpatient hospital facility visit. An outpatient hospital facility visit falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit provided on October 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient psychiatric care provided on August 4 to September 1, 2020.

You asked the Plan to pay for inpatient psychiatric care. You say that the requested care was necessary for the enrollee. The Plan denied your request. The Plan says rules for inpatient psychiatric care have not been met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 psychiatric care. Our reviewer says that the requested services were not medically reasonable and necessary. Our physician reviewer found that the enrollee was admitted to the acute inpatient psychiatric hospitalization on August 4, 2020, with Bipolar Affective Disorder, Generalized Anxiety Disorder, and Unspecified Disorder of Adult Personality and Behavior. Based upon review of the records provided, it was not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, or delusions, and was not showing any behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. It did not appear that active treatment was taking place. 

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 psychiatric care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient psychiatric care provided on August 4 to September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis - adult (D1110), the comprehensive oral evaluation (D0150), and the bitewings - four radiographic images (D0274) received January 12, 2021 from the out-of-network provider.
You asked the Plan to pay for the dental services. You say that the Plan did not pay 50% of the requested claim. The Plan denied your request. The Plan says you may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider.
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 payment is in excess of that which is covered under this benefit. The Plan agreed to pay 50% of the allowable amount for the out-of-network services. As specified in your plan contract, you may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110), the comprehensive oral evaluation (D0150), and the bitewings - four radiographic images (D0274) received January 12, 2021 from the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, pulp vitality tests, two first intraoral periapical x-rays, and two additional intraoral periapical x-rays provided on December 9, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation, pulp vitality tests, and intraoral periapical x-rays. You say that you believe these services should be covered. The Plan denied your request. The Plan says the problem focused limited oral evaluation and pulp vitality tests are not covered benefits. The Plan also says that your benefits for the intraoral periapical x-rays had been satisfied and the frequency limitation had 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, the problem focused limited oral evaluation and pulp vitality tests are not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on November 20, 2020 and your intraoral x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, pulp vitality tests, two first intraoral periapical x-rays, and two additional intraoral periapical x-rays provided on December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) suspension sleeve (L2397) provided October 13, 2020.
You asked the Plan to pay for the orthoses. You say that you trust that the verification provided will be deemed sufficient to allow verification of the claims at issue and to remit payment for the pending claims as soon as possible. The Plan denied your request. The Plan says the services are not documented in the enrollee's medical records.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.
Medicare has specific coverage criteria for each type of orthosis. Based on the records provided, the enrollee did not meet the criteria needed for the orthoses provided. There is no evidence of an established relationship between the enrollee and the ordering physician. There are no services found for the enrollee billed on the services date presented in the documents. There are no claims on file with the ordering physician listed in the enrollee's claims history from 2019 to present. The enrollee did not receive a video or telephonic visit by ordering physician in order to warrant the codes billed. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) suspension sleeve (L2397) provided October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses (V2100, V2020) provided on December 15, 2020.
You asked the Plan to pay for the eyeglasses. You say that you chose to use an out-of-network provider because you felt that you did not need the lens options and could get these glasses at a lower cost. The Plan denied your request. The Plan says you must use an in-network provider to use your routine vision benefits. The provider you chose was out-of-network and therefore payment cannot be made.
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 will cover one pair of select eyewear at no cost to you or will pay up to $150 towards one pair of eyewear per year. These items must be purchased from a network optical provider. We looked at the file and the Plan's rules. You did not use a provider in the Plan's network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses (V2100, V2020) provided on December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on December 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on December 10, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be rendered by an OON provider.
You asked the Plan to pre-approve the dental services. You say that you would like to continue receiving dental services from this provider. The Plan denied your request. The Plan says you are enrolled in a Preferred Provider Organization (PPO), and would have to see this provider using your OON. The Plan also says that no in-network inadequacies are seen.
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 enrolled in a PPO plan, and need to use your OON benefits to see this provider. The record also shows that there are in-network providers available. Therefore, we decided that the Plan does not have to pre-approve dental services to be rendered by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, two prophylaxes, resin-based composite, and drugs or medicaments dispensed in the office for home use provided on February 18, 2020, and September 17, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, prophylaxes, resin-based composite, and drugs or medicaments. You say that you would like these services to be covered. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your plan does not have OON benefits. The Plan also says that you made no contacts to the Plan prior to these dates of service to verify benefits and provider eligibility.
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 100% of the cost for dental services rendered by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, two prophylaxes, resin-based composite, and drugs or medicaments dispensed in the office for home use provided on February 18, 2020, and September 17, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210) of tooth # 2 provided on November 18, 2020.
You asked the Plan to pay for the dental services. You say that you had no idea that the codes the dentist billed were not covered. You also say that these services should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network are not covered. The Plan also says there is no record of a phone call to verify benefits and provider eligibility.
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 extraction is listed as a covered service, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction (D7210) of tooth # 2 provided on November 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for air ambulance services provided on August 28, 2020.
You asked the Plan to waive the copayment for air ambulance services. You say that you feel that you should have received ground transportation instead and disagree with 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 20% coinsurance for air ambulance services. The record shows that you received air ambulance services on August 28, 2020. The allowed amount is $9,080.47 and 20% of that is $1,816.09. You have been asked to pay the total coinsurance amount of $1,816.09 for air ambulance services. Air ambulance services fall within the ambulance 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 air ambulance services provided on August 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinary drainage bag coded A4358 provided on June 29, 2020.
You asked the Plan to pay for the urinary drainage bag. 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 payable.
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 A4358 is urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each. We find that CPT code A4358 is not supported in the medical record. Specifically, this code was billed with modifier NU. The only valid modifiers for this code would be AU, EY, GA, GY, GZ, or KX. This means this code was billed with an inappropriate modifier. Based on this information, we decided that Medicare rules for coverage of the urinary drainage bag have not been met. Therefore, we decided that the Plan does not have to pay for the urinary drainage bag coded A4358 provided on June 29, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider.
You asked the Plan to pay for the psychotherapy. You say that you found a therapist who is able to work with your unique situation. You say that you are seeking to allow coverage for therapy that involves meeting with a therapist and your sons. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 psychotherapy provided by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care and debridement services provided on December 14, 2020.
You asked the Plan to pay for the subsequent nursing facility care and debridement services. You say that these services were provided prior to obtaining authorization to avoid delay in care. The Plan denied your request. The Plan says when an enrollee elects hospice, Original Medicare takes effect on that day, and all services after that date should be billed to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care and debridement services provided on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), and the bone replacement graft for ridge preservation - per site (D7953) received December 9, 2020.
You asked the Plan to pay for the dental services. You say that you cannot afford to pay for the requested services. The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit.
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 extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), and the bone replacement graft for ridge preservation - per site (D7953) received December 9, 2020.