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

We decided that the Plan does not have to pay for the removal of residual tooth roots of tooth #'s 5, 7, and 9 provided by an OON provider on October 28, 2019.
You asked the Plan to pay for the removal of residual tooth roots. The Plan denied your request. The Plan says services are only covered by your Health Plan for dentists that participate in the Plan's network. The Plan also says that the records show that this provider is not in the Plan's 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, the requested items or services are not among those covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the removal of residual tooth roots of tooth #'s 5, 7, and 9 provided by an OON provider on October 28, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on December 11, 2019.You asked the Plan to waive the copayment for the emergency room visit. You say that you believe the doctor's office should be responsible for this bill. 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 $90 copayment per visit for in-network and out-of-network for emergency care. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $90 copayment for the emergency room visit.You have been asked to pay a $20.87 copayment for the emergency room visit. The emergency room 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 copayment for the emergency room visit provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 16, 2019 to November 26, 2019  by an out of network (OON) 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 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 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 November 16, 2019 to November 26, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on December 4, 2019.You asked the Plan to pay for the extraction. You say that this surgery was not planned, but was necessary to remove the tooth.The Plan denied your request. The Plan says this service is not a 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, your plan only allows coverage for simple extractions -non surgical removal. The extraction you requested is not covered under this benefit.Therefore, we decided that the Plan does not have to pay for the extraction provided on December 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on November 2, 2019 by an out of network provider.You asked the Plan to pay forthe ambulance services. You say that the transport was medically necessary.The Plan denied your request. The Plan says ambulance services werenot medically necessary and 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 providersonly 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 service at issue. The Physician Certificate states the enrollee can sit in a wheelchair, therefore, an ambulance was not medically necessary. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on November 2, 2019 by an out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided to the enrollee from September 12, 2019 to September 23, 2019.You asked the Plan to pay forthe SNF services. You say that you would like this reprocessed and paid.The Plan denied your request. The Plan says that the claim has processedcorrectly.The Plan must follow Medicare rules. The rules state that that Medicare secondary payment amounts are determined by a formula and are the lowest of:1) Excess of the actual charge minus the primary payment;2) The amount Medicare would pay if the services were not covered by a primary payer;3) The higher of the Medicare payment amount or the primary payers allowable charge minus the amount actually paid by the primary payer.The breakdown of Medicare secondary payment is as follows:1) $9,050.69 (actual charge) minus $3,410 (amount paid by primary) equals $5,650.692) Amount Medicare would pay $3,410 times 0.8 equals $2,728 (this is the amount Original Medicare would pay, the allowed times 80% coinsurance)3) $3,410 (the higher between theMedicare amount and the primary payers allowable) minus 3,410 (the amount the primary payer paid) equals $0.Medicare will pay the lowest of these amounts. The lowest amount is $0.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided to the enrollee from September 12, 2019 to September 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement of skin services provided on November 1, 2019.You asked the Plan to pay for the debridement of skin services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 11004. 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 that Medicare coverage criteria for the debridement of skin services have not been met.Therefore, we decided that the Plan does not have to pay for the debridement of skin services provided on November 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on November 12, 2019.You asked the Plan to waive the copayment for laboratory services. You say that you have never been charged for laboratory services in the past and disagree with the 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for labs. You have been asked to pay a $20 copayment for laboratory services. Laboratory services fall 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 laboratory services provided on November 12, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forservices provided by American Medical Response on November 2, 2019.You asked the Plan to pay forthenon-emergentambulance services. You say that the service was medically necessary.The Plan denied your request. The Plan says the ambulance service was not medically necessary and you did not request prior authorization.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forservices provided by American Medical Response on November 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on December 31, 2019.You asked the Plan to waive the copayment fora specialist visit. Yousay that you saw your primary care physician and disagree with the 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment per visit to a specialist.The record shows that you had an office visit on December 31, 2019 with a provider other than your primary care physician. Therefore, you are responsible to pay the $35 copayment.  You have been asked to pay a $35 copayment for a specialist visit. A 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 fora specialist visit provided on December 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forservices provided on October 28, 2019.You asked the Plan to pay forthe ambulance services. You say that the service was medically necessary.The Plan denied your request. The Plan says the ambulance service was not medically necessary and you did not request prior authorization.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to payforservices provided on October 28, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on June 18, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment of this service is bundled into other services.
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 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on June 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that these tests were ordered by the treating physician to determine an effective therapy for the enrollee's condition. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.
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 November 15, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services (CPT 99202) provided to you on November 12, 2019.You asked the Plan to pay fortheservices. The Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe chiropractic services (CPT 99202) provided to you on November 12, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided onSeptember 30, 2019 to October 17, 2019 by an out of network (OON) provider.You asked the Plan to pay foroffice visits. You say that due to personal situations you needed evaluation from this provider.The Plan denied your request. The Plan saysthe denial of payment for these services is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forthe medical services provided on September 30, 2019 to October 17, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation for tooth #3.
You asked the Plan to pre-approve the services. You say that this is clinically necessary, as you are a diabetic with high pressure conditions. The Plan denied your request. The Plan says this 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 a bone replacement graft for ridge preservation for tooth #3.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 19, 2019 to November 25, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysician visits. You say that you are requesting payment.The Plan denied your request. The Plan says the denial of payment for these servicesis correct, because this provider is out-of-network with the Plan and authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has topay 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 forthe medical services provided on November 19, 2019 to November 25, 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 office visit provided on October 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 office visit provided on October 14, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient stay provided from December 28, 2019 through January 11, 2020.You asked the Plan to waive the copayment forthe inpatient stay. You say that you had to stay in the hospital until the skilled nursing facility was approved. You say that you shouldn't have to pay for the extra days.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 $225 copayment per day for days 1-7 and a $0 copayment per day for days 8-365.You have been asked to pay a $1,575 copayment for the inpatient stay. ($225/day x first 7 days = $1,575). The inpatient stay 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 copayment forthe inpatient stay provided from December 28, 2019 through January 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto Tablets 24-26mg.You asked the Plan to pre-approveEntresto Tablets. You say that this medication is medically necessary for this enrollee for congestive heart failure.The Plan denied your request. The Plan says this medication is not a covered benefit and does not fall under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveEntresto Tablets 24-26mg.Benefits for Entresto Tabletsmay be available under Medicare Part D. Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from November 17, 2019 to November 24, 2019.

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 are not covered.

The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.

We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from November 17, 2019 to November 24, 2019. 

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.