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

We decided that the Plan does not have to pay for the five oral surgery procedures, six gingival irrigations, and two surgical extractions provided from February 27, 2019, to October 2, 2019.

You asked the Plan to pay for the oral surgery procedures, gingival irrigations, and surgical extractions. You say that you believe these services should be covered. The Plan denied your request. The Plan says the oral surgery procedures and gingival irrigations are not covered benefits. The Plan also says that you had exceeded the limit for extractions.

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 unspecified oral surgery procedure and gingival irrigation are not among those covered under this benefit. The contract says that non-surgical or surgical extractions are limited to two procedures per calendar year. The record shows that you received three surgical extractions on April 3, 2019, two of which were covered by the Plan, and your extractions benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the five oral surgery procedures, six gingival irrigations, and two surgical extractions provided from February 27, 2019, to October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for acupuncture.

You asked the Plan to pre-approve these services. You say that the network provider's facility is unprofessional and dirty. The Plan denied your request. The Plan says the services are available from network providers.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

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 confirmed they have a network provider from which you have not previously received services. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider for acupuncture.

The Qualified Independent Contractor (QIC) read your letter and knows that you may have a quality of care concern. The QIC cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 11, 2020.

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 was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmic ultrasound provided on January 12, 2021.

You asked the Plan to pay for the ophthalmic ultrasound. You say that you had a routine eye exam with no copayment. The Plan denied your request. The Plan says the allowed amount for the procedure is $58.77 which is less than your copayment.

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 $110 copayment for Outpatient Diagnostic Test. 

You have been asked to pay a $58.77 copayment for the ophthalmic ultrasound. The ophthalmic ultrasound falls within the Outpatient Diagnostic Test benefit category. The amount is less than because the allowed amount is less than your required copayment. 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 ophthalmic ultrasound provided on January 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation provided on December 5, 2020.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that ambulance transportation for inpatients is covered under Part A.

We looked at the file and Medicare rules. The records show that the enrollee was an inpatient when the ambulance services were provided. This means that the ambulance services are included in the inpatient pay rate and are not separately payable. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation provided on December 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services rendered on September 10, 2020.

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 procedure code 97530 is 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.

In this case, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes.

We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation supports
that the services were performed by an occupational therapist in a home health or hospice setting and there is a
more appropriate code for these services. 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
therapy services rendered on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for established patient home visit (99348) COVID19 testing (87635) provided on October 15, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the home visit. You say that the enrollee resides in an assisted living facility and could not see an in-network physician who could offer appropriate medical treatment due to decreased availability related to COVID. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 established patient home visit (99348) COVID19 testing (87635) provided on October 15, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the psychiatric services provided on January 1, 2021.

You asked the Plan to waive the copayment for the psychiatric services. You say that you were told it would be covered in full and cannot afford the copayment. The Plan denied your request. The Plan says the 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 $40 copayment for each Medicare-covered outpatient mental health care individual or group therapy visit. Covered services include mental health care individual or group therapy visit mental health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other Medicare-qualified mental health care professional as allowed under applicable state laws. 

You have been asked to pay a $40 copayment for the psychiatric services. The psychiatric services fall within the "Outpatient 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 the psychiatric services provided on January 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for scaling and root planing (D4341) for the lower left and lower right quadrants provided on October 20, 2020.

You asked the Plan to pay for the dental services. You say that you received a denial saying that x-rays were required. You say that you were never given "oral hygiene instruction" which you are being billed $66 for. You also say that this is not a legitimate billing. The Plan denied your request. The Plan says the scaling and root planing is not medically necessary. The Plan says that the documentation submitted does not demonstrate evidence of significant bone loss and/or radiographic root surface calculus on 4 or more teeth per quadrant that is required. The Plan also says that there is no member liability for the oral hygiene instruction.

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 covers the dental services when the services are medically necessary and reasonable.

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 dental services. Our reviewer says that scaling and root planing for 4 or more teeth per quadrant is not medically necessary. Our physician reviewer found the requested code D4341 is reserved for periodontal involvement for 4 or more teeth in a quadrant. The provided documentation does not show at least 4 teeth in each quadrant with significant bone loss. Therefore, the reviewer found that the scaling and root planing for 4 or more teeth per quadrant is not medically reasonable or necessary for the lower left and lower right quadrants.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does
not have to pay for scaling and root planing (D4341) for the lower left and lower right quadrants provided on October 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on December 23, 2020.

You asked the Plan to pay an additional amount for the eyeglasses. You say that you had no documents that informed you of the vision coverage stipend. The Plan denied your request. The Plan says that the Plan paid $175 towards the eyeglasses purchase. This amount is the full stipend allowed for routine vision correction needs per the member's supplemental vision coverage. The benefit maximum had been reached.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $175 toward the purchase of eyeglasses from a network provider. 

We looked at the file and the Plan's rules. The file shows that the Plan paid the vision benefit maximum of $175 for the eyeglasses. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on December 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 7, 2020.

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 was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing
rendered on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction provided on December 8, 2020.

You asked the Plan to pay for eye refraction. You say that the eye refraction was for the eyewear prescription. The Plan denied your request. The Plan says the eye refraction was not performed by the preferred provider.

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 eye refractions during a routine exam are performed by the preferred provider. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for eye refraction provided on December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing - single radiographic image (D0270) received
October 27, 2020.

You asked the Plan to pay for the bitewing x-ray. You say that the x-ray was necessary to determine if your
tooth could be saved. The Plan denied your request. The Plan says the frequency limit for this service 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
in excess of those covered under this benefit. The Plan has submitted evidence that you have exhausted the
frequency limit for this benefit. Therefore, we decided that the Plan does not have to pay for the bitewing -
single radiographic image (D0270) received October 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for breast ultrasound, unilateral, real time with image documentation, including axilla when performed; complete (76641) provided January 14, 2021.

You asked the Plan to waive the copayment for the diagnostic service. You say that you do not agree with the copayment amount as the tests done were supposed to be preventative. The Plan denied your request. The Plan says the claim was processed, and the correct copayment was applied per the Evidence of Coverage.

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 $110 copayment for Medicare covered diagnostic radiology services. 

You have been asked to pay $64.79 the diagnostic service. Since the Medicare allowable amount was less than the copayment amount, you are responsible for the lesser amount. the diagnostic service 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 breast ultrasound, unilateral, real time with image documentation, including axilla when performed; complete (76641) provided January 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for a stay at an IRF on May 21 to June 5, 2020.

You asked the Plan to waive the co-payment for a stay at an IRF. You say that you should not owe a co-payment for a 7-day skilled nursing facility (SNF) stay. The Plan denied your request. The Plan says the providing facility was an IRF and the correct co-payment for IRF care was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $310 co-payment for each day of days 1-7 per admission for a covered inpatient hospital stay.

You have been asked to pay $2,170, or a $310 co-payment for each day of days 1-7 of a stay at an IRF. The medical record confirms that you were transferred to inpatient rehabilitation. A stay at an IRF falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for a stay at an IRF on May 21 to June 5, 2020.

Your complaint about the providing facility being classified as an IRF rather than a SNF 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the emergency department visit (99283) provided June 20, 2020.

You asked the Plan to waive the co-payment for the emergency visit. You say that you were picked up by a Lyft and was out of balance. When the driver dropped you off at the emergency room you went in because you thought the driver knew where he was going. The connect office was at another entrance. The Plan denied your request. The Plan says the claim was processed, and the correct co-payment was applied per the Evidence of Coverage.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $80 copay for Medicare covered emergency room visits for Emergency care.

You have been asked to pay $80 copay for Medicare covered emergency room visits for the emergency visit. the emergency visit 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 co-payment for the emergency department visit (99283) provided June 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and lesion removal provided by an out-ofnetwork
provider on August 14, 2020.

You asked the Plan to pay for the office visit and lesion removal. You say that you are requesting an appeal for
the claim denying for prior authorization. The Plan denied your request. The Plan says care received from a
non-network provider will not be covered.

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 and lesion removal provided by an
out-of-network provider on August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on October 15, 2020, by an
OON provider.

You asked the Plan to pay for home health services. You say that you would like this claim reprocessed and
paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services.

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 home health services provided on October 15,
2020, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive gene panel provided on February 26, 2020.

You asked the Plan to pay for the testing services. You say that the services were provided in good faith. The Plan denied your request. The Plan says there is no documentation that alternative tests are unavailable or clearly equivocal.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The file shows that the enrollee received a comprehensive gene panel for chronic pain syndrome and drug monitoring. The medical records provided do not indicate the results of the testing will directly impact treatment or management of the enrollee. The testing services were requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the comprehensive gene panel provided on February 26, 2020.