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

We decided that the Plan does not have to pay for an office visit provided on October 29, 2019 by an out of network (OON) provider.You asked the Plan to pay for an office visit. You say that the member provided their insurance card. You say that you were unaware that the member had a Dual Complete plan.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 has network providers available who can provide 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 an office visit provided on October 29, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compressor provided on July 24, 2019 by an out of network provider.
You asked the Plan to pay for the compressor. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the compressor provided on July 24, 2019 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient mental health stay from May 22, 2019 to June 12, 2019. You asked the Plan to waive the copayment for an inpatient mental health stay. You say that you were told that you would only owe $395. 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 $395 copayment per day for days 1-4 for inpatient mental health care. You had an inpatient mental health stay from May 22, 2019 to June 12, 2019. Therefore, you are responsible to pay a $395 copayment for days 1-4 (May 22, 2019 to May 25, 2019). $395 (copayment) x 4 (inpatient days) = $1,580. You have been asked to pay the total copayment amount of $1,580 for an inpatient mental health stay. An inpatient mental health stay falls within the inpatient mental health 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 an inpatient mental health stay from May 22, 2019 to June 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical extraction teeth 1 and 28 (D7210) bone replacement graft for ridge preservation tooth 28 (D7953) alveoloplasty in conjunction with extractions teeth 25 and 32 (D7310) provided August 16, 2019.
You asked the Plan to pay for the dental services. You say that you had received information from customer service so you went to this provider. You paid them and you want reimbursement. The Plan denied your request. The Plan says the services are covered but the benefit maximum has 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. The plan has an annual maximum of $1000. Once the annual maximum is exhausted, any remaining charges are your responsibility. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered as benefit maximum has been met. Therefore, we decided that the Plan does not have to pay for surgical extraction teeth 1 and 28 (D7210) bone replacement graft for ridge preservation tooth 28 (D7953) alveoloplasty in conjunction with extractions teeth 25 and 32 (D7310) provided August 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you more forthe prophylaxis (D1110) provided on November 14, 2018.You asked the Plan to reimburse you more forthe dental service. You say that you and your wife both had a cleaning on November 14, 2018. You say that you were reimbursed different amounts for the same service, from the same provider.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says you pay a 50% coinsurance for the dental services that you receive out of network.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 prophylaxis is listed as a covered service, there is a higher cost share when you receive dental services out of network. The record shows that the Plan reimbursed you for this dental servicecorrectlyat the out of network rate. Please note our decision is only about your cost sharing. If you or your wife have questions about her cost sharing, you will need to contact the plan directly.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the interim maxillary partial denture (D5820).
You asked the Plan to pre-approve the interim maxillary partial denture. You say that you do not agree with the Plan's decision. 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 pre-approve the interim maxillary partial denture (D5820).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on November 12, 2019.You asked the Plan to waive the deductible for office visit. You say that you do not understand why you have a deductible for this claim, and you are on a limited income.The Plan denied your request. The Plan says the deductible 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. Your contract with the Plan says that there is $183 deductible for deductible. At the time this claim was processed, $0 of the $183 deductible had been met. The allowed amount of the claim is $63.54, resulting in a deductible obligation of $63.54.The item or service you asked the Plan to waive the deductible for falls within the benefit category Physician/Practitioner Services, Including Doctor's Office Visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $183 deductible for Physician/Practitioner Services, Including Doctor's Office Visits. This cost sharing is a contractual obligation that had not been met at the time office visit was received on November 12, 2019.Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 22, 2019. You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ultrasounds (51798) provided October 29 to December 20, 2019.
You asked the Plan to waive the copayment for the ultrasounds. You say that the copayments should have been included in the surgery you had. The Plan denied your request. The Plan says the correct copayments were 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 $100 copayment for Ultrasounds. You have been asked to pay a $35.48 copayment for each ultrasound. The Medicare allowable copayment is less than the $100 stipulated in the plan contract. 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 ultrasounds (51798) provided October 29 to December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora psychiatric diagnostic evaluation provided on October 20, 2019 by an out of network (OON) provider.You asked the Plan to pay fora psychiatric diagnostic evaluation. You say that it is the facility's responsibility to get prior authorization.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 providerwith the Plan. The Plan has network providers available who can provide 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 fora psychiatric diagnostic evaluation provided on October 20, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 13, 2019 by a non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 13, 2019 by a non-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) services.
You asked the Plan to pre-approve the CT scan. You say that the requested CT is needed to further evaluate the enrollee's submucosal mass prior to their getting the EUS completed. You say that the requested services need to be approved to avoid a delay in the enrollee's care. The Plan denied your request. The Plan says the records do not show that the results of a recent exam done by the enrollee's doctor The Plan says that the records do not show details about what led to this test being requested.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our reviewer says that the requested CT scan is not medically reasonable and necessary. Our physician reviewer found the enrollee recently started experiencing an increase in GI symptoms with weight loss. Endoscopies and stool studies were performed. A small gastric mass and recurrent infectious diarrhea were identified. There are apparently plans to perform an esophageal ultrasound, likely with more definitive biopsies. It is unclear why a CT scan of the stomach needs to be performed prior to the ultrasound. While the enrollee may ultimately require additional imaging, further evaluation/biopsy of the mass is warranted first, so as to determine what additional imaging is 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on
January 7, 2020.
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that the technician messed
up the test and it had to be repeated. 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 diagnostic tests.
You have been asked to pay a $50 copayment for a diagnostic mammogram. A diagnostic mammogram falls
within the outpatient diagnostic tests and therapeutic services and 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 copayment for a diagnostic mammogram provided on January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on November 6, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items orderedand for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have topay fora lumbar-sacral orthosis (L0650) provided to the enrollee on November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the walker and seat attachment provided
on November 18, 2019.
You asked the Plan to waive the coinsurance for the walker and seat attachment. You say that you were not told
about the coinsurance The Plan denied your request. The Plan says that you were charged 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. 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 the walker and seat attachment provided on November 18,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) and provisional crown (D2799).
You asked the Plan to pre-approve the core buildup and provisional crown. The Plan denied your request. The Plan says these services are not covered benefits.
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 a core buildup, including any pins when required (D2950) and provisional crown (D2799).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis RT, LT (L1833) and sleeve RT, LT (L2397)
provided December 9, 2019.
You asked the Plan to pay for the orthoses. You say that you dispensed medically necessary supplies pursuant
to physician orders, which were received by the enrollee. The Plan denied your request. The Plan says the
services are not supported in the medical records received.
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 orthoses. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the documentation in the case file does not support that the requested knee orthoses with
sleeves were medically reasonable and necessary. There is no documentation of recent injury to, or recent
surgical procedure on, the enrollee's right knee, and there is no objective documentation of joint laxity. The
enrollee does not have a left knee.
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 orthoses have not been met.
Therefore, we decided that the Plan does not have to pay for knee orthosis RT, LT (L1833) and sleeve RT, LT
(L2397) provided December 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Ambulance transport (A0427) provided October 14, 2019 by provider.You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost sharing was 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 $125 copayment for Ambulance Services. You have been asked to pay a $125 copayment for the ambulance transport. The ambulance transport falls 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 an Ambulance transport (A0427) provided October 14, 2019 by provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cluneal nerve ablation (64999) provided on October 30, 2019.
You asked the Plan to pay for cluneal nerve ablation. You say that this was medically necessary and billed correctly. The Plan denied your request. The Plan says the enrollee did not get sufficient pain relief from Medial Branch Blocks.
The Plan follows 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 cluneal nerve ablation. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational procedure. Therefore, the procedure is deemed 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 cluneal nerve ablation have not been met. Therefore, we decided that the Plan does not have to pay for cluneal nerve ablation (64999) provided on October 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Low Dose Computed Tomography (LDCT) Lung Cancer Screening performed on December 19, 2019. You asked the Plan to pay for the Lung Cancer Screening. You say that the service was medically necessary. The Plan denied your request. The Plan says this service is only covered once a year. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code G0297 is not supported. Specifically, a Low Dose CT Lung Cancer Screen was already performed in the 12 months before the service at issue. This service is only covered once annually. Based on this information, we decided that Medicare rules for coverage of the Lung Cancer Screening have not been met. Therefore, we decided that the Plan does not have to pay for a Low Dose Computed Tomography (LDCT) Lung Cancer Screening performed on December 19, 2019.