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

We decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis provided on January 12, 2021, by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis. You say that you would like to appeal these services.The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that services are only covered by your Health Plan for in-network dentists.

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 covered when they are received OON.Therefore, we decided that the Plan does not have to pay for,the comprehensive oral evaluation, bitewing x-rays, and prophylaxis provided on January 12, 2021, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient psychiatric care provided on December 18 to December 25, 2020.
You asked the Plan to waive the copayment for inpatient psychiatric care. You say that the assessed copayment is incorrect. The Plan denied your request. The Plan says the correct copayment 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 $100 copayment for each day of days 1-5 for care at an inpatient hospital or inpatient psychiatric facility. You have been asked to pay $500, or a $100 copayment for each day of days 1-5 of a hospital stay for inpatient psychiatric care. Inpatient psychiatric care 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 inpatient psychiatric care provided on December 18 to December 25, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the diagnostic analysis services provided on January 26, 2021.
You asked the Plan to waive the copay for the services provided. You say that you were charged exorbitant copays per visit. The Plan denied your request. The Plan says the claim processed 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 $200 copay for outpatient diagnostic tests. You have been asked to pay $134.44 for the services provided. Because the amount is less than the $200 copay, you were charged the lesser amount. The services fall within the outpatient diagnostic tests 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 copay for the diagnostic analysis services provided on January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology visit provided on November 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the dermatology visit. You say that you were told the provider is in-network The Plan denied your request. The Plan says no prior authorization was obtained, and the provider is non-contract.
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 dermatology visit provided on November 10, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0482) provided on June 26, 2020.
You asked the Plan to pay for drug testing. You say that this is supported by the records. The Plan denied your request. The Plan says this was billed with an incorrect.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0482) provided on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) for tooth # 26, and the
inhalation of nitrous oxide (D9230) provided on September 9, 2019.

You asked the Plan to pay for the extraction of tooth # 26 and the inhalation of nitrous oxide. You say that
these services should be covered. The Plan denied your request. The Plan says inhalation of nitrous oxide is not
listed as a covered service. The Plan also says that the extraction of tooth # 26 has exceeded the benefit
maximum.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
surgical extraction (D7210) for tooth # 26, and the inhalation of nitrous oxide (D9230) provided on September
9, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities services coded 97530 provided on January 8, 2020.
You asked the Plan to pay for the therapeutic activities services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 submitted medical records do not include the time spent on the therapeutic procedure; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities services have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities services coded 97530 provided on January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic visit, and laboratory services provided
by an out-of-network provider on December 1, 2020.
You asked the Plan to pay for the outpatient clinic visit and laboratory services. You say that the information
submitted supports the medical necessity of the services. You say that the claim should be reprocessed. The
Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services
were not approved in advance.
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 outpatient clinic visit, and laboratory services
provided by an out-of-network provider on December 1, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
You asked the Plan to pre-approve an additional ten (10) PT visits. The Plan denied your request. The Plan says an additional ten (10) PT visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 an additional ten (10) PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. The provided records include no notes from physical therapy with regard to the enrollee's symptoms, functional limitations, treatments rendered or outcomes of treatment thus far. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an additional ten (10) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) received
September 11, 2020.
You asked the Plan to pay for the topical application of fluoride varnish (D1206). You say that the enrollee was
not told that the service was not covered. The Plan denied your request. The Plan says the requested service is
not covered by the plan's supplemental 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. The Plan only covers topical application fluoride, excluding varnish
(D1208). Therefore, we decided that the Plan does not have to pay for topical application of fluoride varnish
(D1206) received September 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you are appealing this claim. 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 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 7, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to hold you harmless for the skilled nursing home stay services received from March 11, 2020 to March 27, 2020.

You asked the Plan to hold you harmless for the skilled nursing home stay services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services billed are not payable.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.

You were provided the skilled nursing home stay services by a contract provider. The file does not show that the Plan provided notice that the skilled nursing home stay services would not be covered. Under Medicare rules, this means the skilled nursing home stay services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the skilled nursing home stay services received from March 11, 2020 to March 27, 2020 minus any cost share requirements.

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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 2, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye exam provided on November 12, 2020.
You asked the Plan to waive the copayment for a medical eye exam. You say that you disagree with the charges because now you are being charged two copayments. 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 $30 copayment for medical eye exams for vision care. The medical records show that you received a medical eye exam on November 12, 2020. Therefore, you are responsible to pay the $30 copayment. You have been asked to pay a $30 copayment for a medical eye exam. A medical eye exam falls within the vision 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 a medical eye exam provided on November 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care provided from September 1, 2020, through October 1, 2020.
You asked the Plan to waive the copayment for the SNF care. You say that you were not aware you would be charged a copayment. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
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 $0 copayment each day for days 1 to 20 and a $160 copayment each day for days 21 to 42 for Skilled Nursing Facility (SNF) Care. You have been asked to pay a total cost share of $1600 for the SNF care (10 days x $160 copayment). This care falls within the Skilled Nursing Facility (SNF) 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 skilled nursing facility (SNF) care provided from September 1, 2020, through October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two additional intraoral periapical x-ray images (D0230) provided on January 19, 2021.

You asked the Plan to pay for the x-rays. You say that you had all of your x-rays on the same day at the same time. You do not know why this counts as additional x-rays. The Plan denied your request. The Plan says one intraoral x-ray is covered per calendar year. Three intraoral periapical images were taken on the date in question. The first (D0220) was paid for in full by the Plan. However, the two additional images (D0230) exceed the benefit's maximum and therefore cannot be 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. The Plan can cover one intraoral x-ray procedure code per calendar year. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the additional intraoral x-ray images are requested in a frequency not covered under this benefit. Documentation shows that you had 3 intraoral images taken on the date in question. Intraoral x-rays are coded and billed per the films used, with one image to a film. Each film or image provided counts as a separate procedure code. The Plan covered the first code (D0220) which is described as "intraoral - periapical first radiographic image." The uncovered procedure codes for the additional images (D0230) are described as "intraoral - periapical each additional radiographic image." You had 3 images taken, so you had one first image and two additional images. The billing in this case is correct. Therefore, we decided that the Plan does not have to pay for the two additional intraoral periapical x-ray images (D0230) provided on January 19, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayments for laboratory testing provided on January 8, 2020 and February 10, 2020.

You asked the Plan to waive the copayments for lab tests. You say that you were told that services you received would be reimbursed at the Medicare rate, but the amounts you paid were higher than the Medicare values. The Plan denied your request. The Plan says that the copayment amounts you are being charged are 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 enrollees must pay $0 copayment for each out-of-network covered lab test. 

The Plan says you must pay $20, which is $10 copayment for each lab test. Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment for lab tests. Therefore, we decided that the Plan has to waive the copayments for laboratory testing provided on January 8, 2020 and February 10, 2020.

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.

If the provider is billing you for any charges beyond the applicable cost-sharing, please contact the Plan directly.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a surgical treatment of finger fracture (26765) provided on December 30, 2020.
You asked the Plan to waive the copayment for a surgical treatment of finger fracture. You say that a follow-up surgery at another facility was assessed a lower copayment. The Plan denied your request. The Plan says the correct copayment 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 $350 copayment for Medicare-covered surgery services at a hospital outpatient facility. You have been asked to pay a $350 copayment for a surgical treatment of finger fracture at a hospital outpatient facility. The case record indicates that your follow-up surgery was performed at an ambulatory surgical center, which is a type of facility distinct from a hospital outpatient facility and bearing a separate copayment. A surgical treatment of finger fracture falls within the "Outpatient hospital 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 a surgical treatment of finger fracture (26765) provided on December 30, 2020.