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

We decided that the Plan does not have to pay for oral hygiene instructions (D1330), intraoral x-rays (D0220, D0230), and a panoramic x-ray (D0330) provided on April 26, 2021.
You asked the Plan to pay for oral hygiene instructions, intraoral x-rays, and a panoramic x-ray. You say that your provided should have verified your coverage. The Plan denied your request. The Plan says these services are 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, oral hygiene instructions and intraoral x-rays are not among the services covered under this benefit. Although panoramic x-rays are covered once every three years, the record shows that you last received a panoramic x-ray in 2019. Therefore, we decided
that the Plan does not have to pay for oral hygiene instructions (D1330), intraoral x-rays (D0220, D0230), and a panoramic x-ray (D0330) provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on May 24, 2021.
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 payment is included in the global surgical package.
The Plan must follow Medicare rules. The rules say that post-operative services are included in the global surgical package. We looked at the file and Medicare rules. Billed procedure code 99212 (office visit) was performed within the 90 day global surgical period of major procedure performed on May 24, 2021. Payment for the post-operative office visit is included in the global surgical package. Therefore, we decided that the Plan does not have to pay for the office visit rendered on May 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
February 4, 2021, to February 13, 2021.
You asked the Plan to pay for home health services. You say that you have always billed claims the same way.
The Plan denied your request. The Plan says this was billed with an incorrect type of bill.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim
was submitted with an incorrect type of bill code. Therefore, we decided that the Plan does not have to pay for
the home health services provided to the enrollee from February 4, 2021, to February 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020), sphere lenses (V2100), polycarbonate lenses (V2784) and anti-reflecting coating (V2750) provided on April 5, 2021.

You asked the Plan to pay for eyeglass frames, lenses and anti-reflecting coating. You say that you need these eyeglasses for everyday activities, and you were told the cost of the glasses would be covered by your insurance. The Plan denied your request. The Plan says you exhausted your benefit, and you are responsible for the remaining balance.

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 these services when The Plan contract also says that you have a $300 allowance once per year to use toward the purchase of routine eyewear for contacts, frames, eyeglass lenses and eyewear upgrades at participating network providers. 

We looked at the file and the Plan's rules. The record shows that you purchased frames at an allowed amount of $327.60, sphere lenses at an allowed amount of $108, polycarbonate lenses at an allowed amount of $31.50 and anti-reflective coating at an allowed amount of $85.50. The total amount for this claim is $552.60. The Plan applied the maximum allowed amount, leaving you with a remaining balance of $252.60 ($552.60 - $300 = $252.60). The records also show you exhausted your $300 maximum allowed benefit on April 5, 2021. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames, lenses and anti-reflecting coating have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020), sphere lenses (V2100), polycarbonate lenses (V2784) and anti-reflecting coating (V2750) provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99213) provided to the enrollee on May 3, 2021.
You asked the Plan to pay for the office visit. You say that the enrollee is a type two diabetic who presented with jaw pain, facial swelling, pus and inflammation. You sate the dental provider was not able to see the enrollee for a week. You state the enrollee was assessed for their venous status ulcers, diabetes and anemia. The Plan denied your request. The Plan says the services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. This diagnosis is not covered for the service. The following two categories of services are excluded from coverage: A primary service (regardless of cause or complexity) provided for the care, treatment, removal, or replacement of teeth or structures directly supporting teeth, e.g., preparation of the mouth for dentures, removal of diseased teeth in an infected jaw. A secondary service that is related to the teeth or structures directly supporting the teeth unless it is incident to and an integral part of a covered primary service that is necessary to treat a non-dental condition (e.g., tumor removal) and it is performed at the same time as the covered primary service and by the same physician/dentist. In those cases in which these requirements are met and the secondary services are covered, Medicare does not make payment for the cost of dental appliances, such as dentures, even though the covered service resulted in the need for the teeth to be replaced, the cost of preparing the mouth for dentures, or the cost of directly repairing teeth or structures directly supporting teeth (e.g., alveolar process). Therefore, we decided that the Plan does not have to pay for the office visit (CPT code 99213) provided to the enrollee on May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic parental drug administration (dental code D9610) provided on January 12, 2021.
You asked the Plan to pay for therapeutic parental drug administration. You say that this service was medically necessary. The Plan denied your request. The Plan says services represented by dental code D9610 are not covered under the enrollee's policy. The Plan has paid for the deep sedation services, so those are no longer in dispute.
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 therapeutic parental drug administration (dental code D9610) provided on January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the blood collection procedure from an implanted venous access device you received at an outpatient hospital facility on May 22, 2020.
You asked the Plan to waive the copayment for the blood collection procedure. You say that you do not believe you owe any copayments with this insurance. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this procedure ($110.73) is less than your copayment obligation, you are responsible for the full allowed 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 $225 copayment for outpatient hospital procedures. You have been asked to pay a $225 copayment for the blood collection procedure. The blood collection procedure falls within the outpatient hospital procedures 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 blood collection procedure from an implanted venous access device you received at an outpatient hospital facility on May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation and management service (99442) rendered by the out-of-network (OON) provider on April 26, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of 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 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 telephone evaluation and management service (99442) rendered by the out-of-network (OON) provider on April 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 5, 2021 to January 15, 2021.
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 claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 pay for the laboratory services rendered on January 5, 2021 to January 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing provided on
January 4, 2021.
You asked the Plan to waive the copayment for the laboratory testing. You say that you did not go to the
hospital for tests or procedures on this day and this claim appears to be in error and does not make sense
because it was billed as a cytopathology for a female, and you are a male. The Plan denied your request. The
Plan says you are financially liable for the copayment. The documentation supports that the cytopathology was
related to the renal presentation.
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 $12
copayment for Laboratory Tests (outpatient).
You have been asked to pay a $12 copayment for the laboratory testing. The laboratory testing falls within the
Laboratory Tests (outpatient) 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 laboratory
testing provided on January 4, 2021
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transport services and emergency room services provided on April 7, 2021.
You asked the Plan to waive the copayment for ambulance transport services and emergency room services. You say that these services were unnecessary, and you should not be financially responsible for the copayments. The Plan denied your request. The Plan says the claims were processed appropriately according to your benefit, applying the applicable member cost-sharing for both services.
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 ambulance services, and a $120 copayment for emergency care. You have been asked to pay a $100 copayment for ambulance transport services and a $120 copayment for emergency room services. Ambulance transport services falls within the Ambulance Services benefit category, and emergency room services falls within the Emergency 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 ambulance transport services and emergency room services provided on
April 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotic items provided on November 3, 2020.
You asked the Plan to pay for orthotic items. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these items is correct, because the documentation does not support the need for the billed supply codes.
The Plan must follow Medicare rules. Medicare rules say that proof of delivery is required for payment of DMEPOS items. We looked at the file and Medicare rules. The documentation submitted does not include valid proof of delivery for the specific DMEPOS items billed on this claim. Based on this information, we decided that Medicare rules for coverage of orthotic items have not been met. Therefore, we decided that the Plan does not have to pay for orthotic items provided on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 3, 2021 by an non-participating 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-participating 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided on February 3, 2021 by an non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on February 21, 2020.

You asked the Plan to pay for the dental services. You say that you mailed the form on February 9, 2021 and cannot control the time of the mail. The Plan denied your request. The Plan says the claim was untimely for being submitted more than 335 days following the date of service.

The Plan follows Medicare rules. 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 record shows that a claim for the dental services was not filed until March 4, 2021. This means that more than 335 from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for dental services provided on February 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy and esophagogastroduodenoscopy provided
on April 5, 2021.

You asked the Plan to pay for colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by
snare technique (45385) and esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple
(43239). You say that you want the surgeon to be paid. The Plan denied your request. The Plan says medical
records were requested but not received so the services are not supported.

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 the codes are not supported in the medical record. Specifically, there are no physician medical
records of the procedures. Based on this information, we decided that Medicare rules for coverage of
colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique (45385) and
esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple (43239) have not been met.
Therefore, we decided that the Plan does not have to pay for the colonoscopy and esophagogastroduodenoscopy 
provided on April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotics (L0650, L3960) provided on December 14, 2020.
You asked the Plan to pay for orthotics. You say that these items were medically necessary. The Plan denied your request. The Plan says the documentation is not sufficient to support these items.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. There is not an itemized delivery ticket to verify the specific supplies that were provided. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for orthotics (L0650, L3960) provided on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the partial denture provided on March 9, 2021.
You asked the Plan to waive the coinsurance for mandibular partial denture (D5214). You say that the dentist overcharges you each time you go. The Plan denied your request. The Plan says you were charged the coinsurance and deductible 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 50% coinsurance for Major Dental Services. You have been asked to pay 50% coinsurance for mandibular partial denture (D5214) and a $100 deductible. The mandibular partial denture (D5214) falls within the Major Dental 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 pay for the partial denture provided on March 9, 2021.
Please note, this decision is for the date of service March 9, 2021 only. Please contact the Plan with questions about other dates of service.
Your complaint is not a valid appeal for medical coverage. 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: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance service, basic life support, emergency transport provided on
March 6, 2021.
You asked the Plan to pay for ambulance service, basic life support, emergency transport. You say that the
ambulance transport was medically necessary. The Plan denied your request. The Plan says that the enrollee
could have been safely transported by another type of motor vehicle, possibly a van transport vehicle.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same rules.
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 ambulance service, basic life support,
emergency transport. Our reviewer says that the ambulance transport was medically necessary. Our physician
reviewer found that the enrollee's presenting symptoms met prudent layperson criteria for emergency care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ambulance service, basic life support, emergency transport have been met.
Therefore, we decided that the Plan has to pay for ambulance service, basic life support, emergency transport
provided on March 6, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.