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

We decided that the Plan does not have to pay for the home visit provided on January 9, 2021 by an out of network provider.
You asked the Plan to pay for the home visit. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the services were not urgent nor 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 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 home visit provided on January 9, 2021 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the binaural behind the ear hearing aid (V5140) received
December 7, 2020, from the non-Plan hearing vendor.
You asked the Plan to pay for the binaural behind the ear hearing aid (V5140). You say that the Plan should
apply the $500 benefit allowance towards the hearing aid purchase. The Plan denied your request. The Plan
says hearing aids obtained outside of the Plan's hearing vendor network are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when purchased through the Plan's hearing vendor network.
We looked at the file, and the Plan's rules. You purchased your hearing aid outside the Plan's hearing vendor
network. Based on this information, we decided that the Plan's rules for coverage of the binaural behind the ear
hearing aid (V5140) have not been met. Therefore, we decided that the Plan does not have to pay for the
binaural behind the ear hearing aid (V5140) received December 7, 2020, from the non-Plan hearing vendor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 30, 2020.
You asked the Plan to waive the copayment for the office visit. You say that there are no orthopedic specialists in your geographical area who specialize in cervical problems. You say that you have limited funds to see necessary doctors and you request to only pay $35. The Plan denied your request. The Plan says the out-of-network copayment applied 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 $65 copayment for provider and professional services at an out-of-network specialist's office.
You have been asked to pay a $65 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show the provider is an out-of-network specialist. 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 office visit provided on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions (D7310) and removal of torus palatinus (D7472).
You asked the Plan to pre-approve alveoloplasty in conjunction with extractions and removal of torus palatinus. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered 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 pre-approve alveoloplasty in conjunction with extractions (D7310) and removal of torus palatinus (D7472).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided August 12, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says there was no evidence of an established relationship between the provider and the enrollee.
The Plan follows Medicare rules. Medicare rules say that the lumbar-sacral orthosis is subject to the criteria listed in the Medicare rules section. 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 lumbar-sacral orthosis. Our reviewer says that the requested item was not medically necessary and reasonable. Our physician reviewer found that an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back. 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the comprehensive oral evaluation - new or established patient (D0150), bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230) and prophylaxis - adult (D1110) provided February 16, 2021.

 You asked the Plan to waive the copayments for the comprehensive oral exam, bitewing x-rays, intraoral x-rays and dental cleaning. You say that the provider has charged you a fee for the visit and you shouldn't have a copay. The Plan denied your request. The Plan says the cost of the services is less than the required copayment and the cost share has been applied 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). 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. Your contract with the Plan clearly says that you must pay a $15 copayment for comprehensive oral exams and dental cleanings and a $25 copayment for x-rays.

We looked at the file and Medicare rules. In this case the dental office has charged less than your copayments for the services in question. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the comprehensive oral evaluation - new or established patient (D0150), bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230) and prophylaxis - adult (D1110) provided February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), 
panoramic x-ray (D0330), cleaning (D1110), re-cementing or re-bonding of crown (D2920) and extraction (D7140) provided from August 5, 2020, to September 18, 2020, by an out-of-network provider.

You asked the Plan to pay for the dental services. You say that you were led to believe that your dentist was in-network. The Plan denied your request. The Plan says out-of-network dental care 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.

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 comprehensive oral evaluation (D0150), bitewing x-rays (D0274), panoramic x-ray (D0330), cleaning (D1110), re-cementing or re-bonding of crown (D2920) and extraction (D7140) provided from August 5, 2020, to September 18, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency department visit provided on
January 17, 2020, to January 19, 2020.

You asked the Plan to waive the copayment for an emergency department visit. You say that you do not
understand why you are being charged a copayment when you were admitted into the hospital the same day
you were in the emergency room. The Plan denied your request. The Plan says the copayment you are being
charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75
copayment for emergency care. Your contract with the Plan also clearly says that if you are immediately
admitted to the hospital form the Emergency Department, then the $75 copayment is waived.

You have been asked to pay a $75 copayment for an emergency department visit. The records show that you
went to the emergency room and were not admitted into the hospital but placed in observation while tests were
conducted. The EOC confirms that $75 is the required copayment for this service. 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 emergency department visit provided on January 17, 2020, to January 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided
on November 6, 2020, through November 23, 2020.
You asked the Plan to waive the copayment for SNF care. You say that you should not responsible for the cost
share. The Plan denied your request. The Plan says the cost share was applied 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 $160
copayment each day 21 through 39 for skilled nursing facility (SNF) care.
You have been asked to pay a $160 copayment each day 21 through 39 for SNF care ($160 x 14= $2,240).
However, you only had $1,436 left of your out of pocket maximum, and therefore, were only charges the
$1,436. This service falls within the skilled nursing facility (SNF) 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 skilled nursing facility (SNF) care provided on November 6, 2020,
through November 23, 2020.
Your complaint about the facility potentially keeping you longer then needed 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 the services provided by an out-of-network provider on October 12, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-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 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 services provided by an out-of-network provider on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam and diagnostic testing provided by a participating provider on March 26, 2021.
You asked the Plan to waive the copayment for an eye exam and diagnostic testing. You say that you went for a normal eye exam. You say that you do not agree with these copayments. The Plan denied your request. The Plan says the correct copayments have 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 $40 copayment for vision care/other providers and a $10 copayment for outpatient diagnostic tests/diagnostic tests.
You have been asked to pay a $40 copayment for an eye exam and a $10 copayment for diagnostic testing. The total amount you are being asked to pay is $50 ($40 + $10 = $50). The correct copayments have been applied to the services that were provided. An eye exam falls within the vision care/other providers benefit category and diagnostic testing falls within the outpatient diagnostic tests/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 an eye exam and diagnostic testing provided by a participating provider on March 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81230, 81231, 81232, 81240, 81241, 81283,
81328, 81335, 81350, 81408, 81479) provided on September 3, 2020.
You asked the Plan to pay for genetic testing. You say that this was medically necessary. The Plan denied your
request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. If a laboratory assays two or more genes in a
patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes
a single procedural service, so one code must be submitted for the panel.
We find that CPT code 81230, 81231, 81232, 81240, 81241, 81283, 81328, 81335, 81350, 81408, and 81479 is
not supported in the medical record. Specifically, the records shows that the genes tested were tested in parallel
and should be reported with a single code. Based on this information, we decided that Medicare rules for
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for
genetic testing (81230, 81231, 81232, 81240, 81241, 81283, 81328, 81335, 81350, 81408, 81479) provided on
September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified adjunctive procedures (D9999) provided on December 2, 2020.

You asked the Plan to pay for the unspecified adjunctive procedures. You say that you were told this provider was in-network. The Plan denied your request. The Plan says they have agreed to cover the extractions and the evaluation; however, the unspecified adjunctive procedures are not covered by the Plan under normal circumstances. The Plan also states that additional information from the provider indicated the correct codes for these services are D9222 and D9223 (deep sedation/general anesthesia). None of the provided codes are listed as covered under the dental 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 unspecified adjunctive procedures (D9999) provided on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on January 20, 2021.
You asked the Plan to pay for the office visit. You say that you attached the medical records for review and the claim should be reprocessed. The Plan denied your request. The Plan says prior authorization was required but 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 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 office visit provided by an out-of-network provider on January 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on September 11, 2020.
You asked the Plan to pay for therapeutic exercises. You say that this should be covered. The Plan denied your request. The Plan says this was not billed correctly.
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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the records show this service was provided in a home health setting. There is a more appropriate code for this service. Based on this information, we decided that Medicare rules for coverage of therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on September 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the bronchodilation responsiveness spirometry provided on August 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the bronchodilation responsiveness spirometry. You say that the order for this test was from an in-network doctor. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 bronchodilation responsiveness spirometry provided on August 18, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0330, D9310) received January 11,
2021, from the Medicare opt-out provider.

You asked the Plan to pay for the dental services (D0330, D9310). You say that the Plan gave you the name
and number of this provider. The Plan denied your request. The Plan says if you receive services from a
provider who does participate in Medicare you will be responsible for paying the full cost of the services you
receive.

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. The Plan has submitted evidence that this provider was opted out of
Original Medicare on this date of service. Therefore, we decided that the Plan does not have to pay for the
dental services (D0330, D9310) received January 11, 2021, from the Medicare opt-out provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 13, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed services cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation.

We looked at the file and Medicare rules. The records do not show that there is an established relationship between the ordering physician and the enrollee. The records do not indicate the results of the testing would be used in the management of a specific medical problem. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 13, 2020.