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

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) provided on July 18, 
2020. 
 
You asked the Plan to pay for the dental item. You say that your dentures were over 25 years old. You say that 
the provider was not able to restore your denture. You say that your denture has cracked and is causing 
discomfort. You say that it does not want to say in your mouth and as a result is irritating your gums and the 
roof of your mouth. You also say that you cannot afford to pay for this as you are on a fixed income. The Plan 
denied your request. The Plan says the complete upper denture 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 complete upper denture is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
complete upper denture (D5110) provided on July 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on October 26, 2019.
You asked the Plan to waive the coinsurance for DME. You say that you feel that the provider submitted the claims incorrectly. 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 DME and related supplies. You received DME on October 26, 2019. The allowed amount is $268.04 and 20% of that is $53.61. You have been asked to pay the total coinsurance amount of $53.61 for DME. DME falls within the DME and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for DME provided on October 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forambulance services provided on July 22, 2020.You asked the Plan to waive the copayment forambulance services. You say that you were told that you would not owe a 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 $250 copayment for ambulance services.You have been asked to pay a $250 copayment for ambulance services. 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 forambulance services provided on July 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mohs surgery.

You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that Mohs surgery is covered when specific criteria are met.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have squamous cell skin cancer of the right lower limb, including the hip. Based on the records, the use of Mohs surgery does not meet the Medicare criteria for coverage. The services are therefore not reasonable or medically necessary at this time.

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve Mohs surgery.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (71045) provided on July 11, 2020. 
 
You asked the Plan to pay for an x-ray. You say that this should be covered. The Plan denied your request. The 
Plan says this was not billed with a necessary modifier. 
 
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, we have confirmed that code an 
71045 has a Column One/Column Two relationship with code 71101, which was billed on a separate claim by 
the same provider for the same date of service, and cannot be paid as billed. This code cannot be paid as a 
separate line item without an appropriate modifier. Based on the claim submitted, Medicare billing criteria have 
not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided on July 
11, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on July 8, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that this ambulance transportation was 
medically necessary. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 8, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2 ventilators provided on June 17, 2020. 
 
You asked the Plan to pay for the durable medical equipment (DME). You say that the ventilators are 
medically necessary. You say that they are not duplicates. You also say that they are both payable. The Plan 
denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
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 date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the 2 ventilators provided on June 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forambulance services provided on June 26, 2020.You asked the Plan to waive the copayment forambulance services. You say that you did not request to be transferred to another facility 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 a $50 copayment for ground ambulance services for transportation. You have been asked to pay a $50 copayment for ambulance services. Ambulance services fall within the transportation 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 forambulance services provided on June 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair provided by Wellness Medical Supply, LLC 
on July 7, 2020. 
 
You asked the Plan to pay for a shower chair. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower chair provided by Wellness 
Medical Supply, LLC on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 17, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior 
authorization was not obtained as required under the plan benefits. 
 
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 
physician's services. 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 physician's services provided on August 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic radiology services provided 
on May 5, 2020. 
 
You asked the Plan to waive the copayment for the magnetic resonance angiography and magnetic resonance 
imaging. You say that you were told your copayment would be zero. The Plan denied your request. The Plan 
says you were charged this copayment 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 $125 
copayment for each outpatient diagnostic tests.  
 
You have been asked to pay a $125 copayment for the magnetic resonance angiography and $125 copayment 
for the magnetic resonance imaging. The magnetic resonance angiography and magnetic resonance imaging 
fall within the outpatient diagnostic tests 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 diagnostic radiology services provided on May 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cataract surgery provided on August 17, 2020.
You asked the Plan to waive the copayment for a cataract surgery. You say that you feel that the charges are too high. 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 $200 copayment for outpatient surgery. You have been asked to pay a $200 copayment for a cataract surgery. A cataract surgery falls within the outpatient surgery 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 cataract surgery provided on August 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co payments for the changing of cystostomy tubes provided.

You asked the Plan to waive the co payments for the changing of cystostomy tubes. You say that you feel that the charges are too high for such a simple procedure.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 co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 co payment for outpatient surgery.

You received the changing of cystostomy tubes. The changing of cystostomy tubes is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $227.36, which is less than the $250 co payment.

You received the changing of cystostomy tube. The changing of cystostomy tubes is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $227.36, which is less than the $250 co payment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided by a 
participating provider on August 3, 2020. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you think this should 
only be $10. 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 $15 
copayment for urgently needed services/urgently needed services.  
 
You have been asked to pay a $15 copayment for urgently needed services. Urgently needed services fall 
within the urgently needed services/urgently needed 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 urgently needed services provided by a participating provider on August 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided from July 8, 2020, to July 11, 2020.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that this was supposed to be an outpatient hospital stay and you 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 a $325 copayment for days 1-5 for inpatient hospital care. The medical records show that you had an inpatient hospital stay from July 8, 2020, to July 11, 2020. Therefore, you are responsible to pay a $325 copayment for days 1-3 (January 8, 2020, to January 10, 2020). $325 (copayment) x 3 (inpatient days) = $975. You have been asked to pay the total copayment amount of $975 for an inpatient hospital stay. An 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 foran inpatient hospital stay provided from July 8, 2020, to July 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemagnetic resonance imaging (MRI) of the jaw joint.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that the enrollee has jaw pain and an x-ray that showed dislocation. There is no documentation of a trial and failure of six weeks of conservative management, including provider-directed treatment, a clinical re-evaluation, and a detailed examination. Without this documentation, the MRI is not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. 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 pre-approvemagnetic resonance imaging (MRI) of the jaw joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two extractions and panoramic x-ray provided on May
18, 2020, by an OON provider.
You asked the Plan to pay for the extractions and panoramic x-ray. The Plan denied your request. The Plan
says these services were rendered by a non-participating 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 items or services are not
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the two
extractions and panoramic x-ray provided on May 18, 2020, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections provided by a participating provider on December 16, 2019, to July 6, 2020.You asked the Plan to waive the coinsurance for injections. You say that this provider was in-network. You say that this coinsurance is too high. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Medicare Part B prescription drugs/in-network. You have been asked to pay less than a 20% coinsurance of the allowed amount for injections. The total allowed amount is $37,788.63. Your 20% coinsurance is $7,557.73 ($37,788.63 x 20% = $7,557.73). You have been asked to pay$5,572.50, which is less than your 20% coinsurance. Injections fall within the Medicare Part B prescription drugs/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for injections provided by a participating provider on December 16, 2019, to July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient urgent care office visit (99213) provided on May 27, 2020.You asked the Plan to waive the copayment forthe urgent care visit. You say that you feel that you should not have received a copayment because this appointment was Coronavirus-related. You received a Coronavirus antibody test at the urgent care and had to do the follow up.The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the plan benefits.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 $40 copay for each urgent care visit. You have been asked to pay $40 copay the urgent care visit. The urgent care visit falls within the Urgently needed services benefit category. This means that you havebeen 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 forthe outpatient urgent care office visit (99213) provided on May 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiological services (70496, 70498, 71045) provided.

You asked the Plan to pay for radiological services. You say that this was not a duplicate claim.The Plan denied your request. The Plan says additional units of these codes are not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.

We find that an additional unit of CPT codes 70496, 70498, 71045 are not supported in the medical record. The medical record only supports 1 unit of each CPT code 70496, 70498, 71045, which was previously billed and paid for this provider, enrollee, and date of service. Based on this information, we decided that Medicare rules for coverage of radiological services have not been met.Therefore, we decided that the Plan does not have to pay for radiological services (70496, 70498, 71045) provided
















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Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the ambulance services provided.

You asked the Plan to waive the co payment for the ambulance services. You say that the ambulance service was medically necessary.The Plan denied your request. The Plan says the services are covered and you were charged this cost sharing 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 $260 co payment for each ambulance trip. You had one ambulance trip. The Plan charged you $260 for these services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the co payment for the ambulance services provided