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

We decided that the Plan does not have to pay for the extraction, first 15 minutes of deep sedation/general anesthesia, each subsequent 15 minute increment of deep sedation/general anesthesia, and biopsy of bone provided on November 25, 2019.
You asked the Plan to pay for the extraction, deep sedation/general anesthesia services, and biopsy of bone. You say that a cyst was found in your jaw and was removed by the dentist with a tooth extraction. You also say that you paid the dentist in full. The Plan denied your request. The Plan says the treating provider is listed as an opt out provider. The Plan also says that you were advised that this provider does not accept any form of insurance and must be paid in full at the time of service.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the treating provider. This provider has opted out of the Medicare program. The file shows that the treating provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the extraction, first 15 minutes of deep sedation/general anesthesia, each subsequent 15 minute increment of deep sedation/general anesthesia, and biopsy of bone provided on November 25, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical assistant services on a colonoscopy (45385) provided on December 19, 2019.You asked the Plan to pay forsurgical assistant services. You say that these services were required by hospital policy.The Plan denied your request. The Plan says surgical assistant services arenot covered for this procedure.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 45385. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find thatMedicare coverage criteria for surgical assistant services have not been met.Therefore, we decided that the Plan does not have to pay forsurgical assistant services on a colonoscopy (45385) provided on December 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital stay and physician services provided from September 30, 2019 to January 20, 2020.You asked the Plan to waive the copayments for the inpatient hospital stay and the physician services. You say that you should not be responsible for the cost share amounts.The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $300 copayment per day, days 1-6 and a $0 per day, days 7-90 for in-network inpatient hospital care and a $35 copayment for in-network physician specialist services. You have been asked to pay a $300 copayment for each day for days 1 to 3 of your inpatient hospital stay. ($300 x 3 = $900). You have also been asked to pay a $35 copayment for each of the physician services.($35 x 3 = $105). ($900 + $105 = $1,005). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The physician services fall within the "Physician/Practitioner services, including doctor's office visits" 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 copayments for the inpatient hospital stay and the physician services provided September 30, 2019 to January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (CPT 01936) provided on October 21, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 60-year-old female with a history of cervical radiculopathy who underwent a cervical epidural steroid injection (C7/T1) under fluoroscopy with contrast confirmation. The enrollee received monitored anesthesia care (MAC) for the percutaneous image guided procedure. An anesthesiology record was not available with the medical records submitted. The review indicates that there was no documentation provided necessitating the use of MAC for a cervical epidural steroid injection. The requested anesthesia services were not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services (CPT 01936) provided on October 21, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.You asked the Plan to pre-approve the additional routine transportation trips. You say that you need to go to dialysis 3 times a week and you are in a wheelchair. You say that you need to continue your dialysis or you will die. You say that you cannot lift a wheelchair and put it in a car to drive yourself.The Plan denied your request. The Plan says your routine transportation benefit is exhausted.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 50 one-way routine transportation trips per calendar year. We looked at your request, the records in the case file, and the rules. The records show that you received coverage for 55 one-way routine transportation trips in the 2020 calendar year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on November 1, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that this will cause a financial hardship.The Plan denied your request. The Plan says that copayments are a member's contractual obligation.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 per one-way ambulance trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the one-way ambulance trip 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 forthe ambulance transport provided on November 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on November 12, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the services are an extension of the initial visit.The Plan denied your request. The Plan says there is no network deficiency for the services, and alternate network providers were found.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 has network providers available who can provide 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 OON services.Therefore, we decided that the Plan does not have to pay forthe lab services provided on November 12, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forprogressive lenses (V2781) provided on January 12, 2020.You asked the Plan to pay forprogressive lenses. You say that these lenses are recommended and necessary for you.The Plan denied your request. The Plan says this type of lens is not covered by the Plan.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 routine eyewear, but not lens optionssuch as progressives.We looked at the file and the Plan's rules. The lenses at issue are progressive lenses, which are excluded from coverage.Based on this information, we decided that the Plan's rules for coverage of progressive lenses have not been met.Therefore, we decided that the Plan does not have to pay forprogressive lenses (V2781) provided on January 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forendovenous ablation therapy provided on January 8, 2020.You asked the Plan to waive the deductible forendovenous ablation therapy. You say that you disagree with the out-of-network 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. Your contract with the Plan says that there is a $650 deductible for out-of-network outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received endovenous ablation therapy from an out-of-network provider on January 8, 2020. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The record shows that you had only paid $93.06 toward the $650 deductible. Therefore, you are responsible to pay the allowed mount of $359.82. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $650 deductible for out-of-network outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time endovenous ablation therapy was received on January 8, 2020.Therefore, we decided that the Plan does not have to waive the deductible forendovenous ablation therapy provided on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) provided on January 30, 2020.You asked the Plan to pay for the extraction. You say that a plan provider recommended that you have this procedure done.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 extraction (D7140) provided on January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe core build up (D2950) and crown (D2740) provided on October 16, 2019.You asked the Plan to pay forthe dental services. You say that when you called your plan after receiving the services. You say that you were advised if you had signed up for the dental rider, the plan would have covered the crown at 50%. You also say that you did not know that you had the ability to purchase a rider.The Plan denied your request. The Plan says the core build up and crown are not covered services.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 core build up and crown are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe core build up (D2950) and crown (D2740) provided on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and bitewings provided on December 12, 2019.
You asked the Plan to pay for the prophylaxis and bitewings. You say that you have been going to this dentist for years and have never had to pay out of pocket. You also say that you do not think you should be held responsible for these charges. The Plan denied your request. The Plan says you met the Plan's annual maximum of $500 while processing this claim.
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 Plan offers a $500 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on December 12, 2019 and your annual maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis and bitewings provided on December 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on January 6, 2020.You asked the Plan to pay for the paramedic intercept services. You say that you were not informed that a separate crew was being called for. The Plan denied your request. The Plan says this item is not a covered benefit.The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area.Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe endodontic therapy provided on December 19, 2019.You asked the Plan to pay forthe endodontic therapy. You say that you needed a root canal and a temporary cap was installed because the old cap fell off. You also say that you had not used up your dental allowance.The Plan denied your request. The Plan says this service is 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 pay forthe endodontic therapy provided on December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the walker and seat attachment provided on October 31, 2019.
You asked the Plan to provide additional payment for the walker and seat attachment. You say that you would like more reimbursement for these items. The Plan denied your request. The Plan says that you were reimbursed 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 20% coinsurance for durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for the walker and seat attachment. The walker and seat attachment falls within the durable medical equipment (DME) and related supplies benefit category. The Plan has paid 80% of the Medicare allowable rate. 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 provide additional payment for the walker and seat attachment provided on October 31, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe inpatient services provided from September 10, 2019 to September 13, 2019.You asked the Plan to pay forthe inpatient services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the services rendered were not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pay for the inpatient services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presented to the hospital for evaluation of syncope. The enrollee's work-up revealed multi vessel coronary artery disease, for which the enrollee subsequently received intervention. The documentation supports that the entire inpatient stay was medically reasonable and necessary.We note that the plan found that criteria was met for dates of service of September 10, 2019 and September 11, 2019 and denied September 12, 2019. However, our physician reviewer found that the entire inpatient stay was medically reasonable and 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 the inpatient services have been met.Therefore, we decided that the Plan has to pay forthe inpatient services provided from September 10, 2019 to September 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the laboratory work and the injections provided on January 15, 2020 and January 29, 2020.You asked the Plan to waive the cost share for the laboratory work and the injections. You say that you were told that labs were covered. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $10 copayment per day, per provider, for in-network Medicare-covered lab services and 20% coinsurance for each in-network Medicare-covered Part B chemotherapy drug and Part B drugs obtained in a provider's office or outpatient setting. You have been asked to pay a $10 copayment for the laboratory work on each date of service. ($10 + $10 = $20). You have also been asked to pay $117.05 which is 20% of the allowed amount the injections on each date of service. The allowed amount is $585.23. ($585.23 x 20% = $117.05). ($117.05 + $117.05 = $234.10). The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The injections fall within the "Medicare Part B prescription drugs"benefit category.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on January 27, 2020.
You asked the Plan to waive the copayment for specialist visit. You say that this was a follow-up visit, and you were told there would not be a copayment. The Plan denied your request. The Plan says the copayment amount 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 $50 copayment for specialist office visit. You have been asked to pay $50 copayment for specialist visit. Specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 office visit provided on January 27, 2020.
Your complaint regarding receiving inaccurate information about the cost-share for this service is considered to be a grievance. Please contact the Plan for more information about your grievance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foranti-reflective coating, per lens (V2750) and spherocylinder, trifocal, plano to plus or minus 4.00d sphere, .12-2.00d cylinder, per lens (V2303) provided on April 16, 2019.You asked the Plan to pay forthe eyewear. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.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. You exhausted your maximum benefit allowance, because the plan paid the $150 and you are responsiblefor the remainder of the cost. Your EOC states, if the eyewear you purchase costs more than $150, you pay the difference.Therefore, we decided that the Plan does not have to pay foranti-reflective coating, per lens (V2750) and spherocylinder, trifocal, plano to plus or minus 4.00d sphere, .12-2.00d cylinder, per lens (V2303) provided on April 16, 2019.