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

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), the complete series x-ray (D0210), and the unspecified preventive service (D1999) provided on January 21, 2021.

You asked the Plan to pay for the dental services. You say that there was no payment made on this claim. You say that these services were needed for preventive service to keep your gums from further deteriorating. You also say that you would like this claim to be reprocessed and paid. The Plan denied your request. The Plan says comprehensive periodontal evaluation is not listed as a covered service. The Plan says that complete series x-ray is not listed as a covered service. The Plan also says that unspecified preventive service is not listed as a covered service either.

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 comprehensive periodontal evaluation (D0180), the complete series x-ray (D0210), and the unspecified preventive service (D1999) provided on January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on December
18, 2020.
You asked the Plan to pay for the dental service. You say that you believe that this dentist is in network. You
also say that you should owe $0. The Plan denied your request. The Plan says limited oral evaluation is not
listed as a covered service.
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
limited oral evaluation (D0140) provided on December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on October 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 physician services provided on October 20, 2020 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 for an inpatient stay provided from October 23, 2020, to October 30, 2020.
You asked the Plan to waive the copayment for an inpatient stay. You say that you were told that you would not owe a copayment. 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 $350 copayment for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from October 23, 2020, to October 30, 2020. Therefore, you are responsible to pay a $350 copayment for days 1-5 (October 23, 2020, to October 27, 2020). $350 (copayment) x 5 (inpatient days) = $1,750. You have been asked to pay the total copayment amount of $1,750 for an inpatient stay. An 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 for an inpatient stay provided from October 23, 2020, to October 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ultrasound provided on April 30, 2020.
You asked the Plan to reduce the copayment for the ultrasound. You say that the ultrasound is not a radiological test, it is sound waves. You say you should pay a $20 copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $125 copayment for each in-network Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). You have been asked to pay a $125 copayment for the ultrasound. The ultrasound falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows the ultrasound is considered a radiological service. 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 reduce the copayment for the ultrasound provided on April 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office services to be provided by an OON provider.
You asked the Plan to pre-approve office services. You say that your condition is spreading, and you require
treatment at this provider because they specialize in your condition. The Plan denied your request. The Plan
says the denial of authorization for these services is correct, because this provider is out-of-network with the
Plan, and you can be treated by an in-network provider.
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. 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
office services to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 laboratory services provided on October 21, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation submitted does not show that the enrollee's diagnosis meets the criteria of painful, debilitating, osteoporotic vertebral collapse/compression fractures.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have greater than 25% vertebral body height loss and from the pain scales. It does not appear that there is severe pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebral augmentation for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural steroid injections.
You asked the Plan to pre-approve epidural injections. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee did not have significant or sustained pain relief with previous injections.
The Plan follows Medicare rules. Medicare rules state that lumbar epidural injections may only be covered under certain clinical indications with limitations. 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 epidural injections. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested epidural. Our physician reviewer found there is no role for a series of three epidural steroid injections, and the enrollee has not achieved significant and sustained pain relief from period injections. Therefore, this request is considered not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epidural injections have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural steroid injections.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care provided on November 13, 2020.
You asked the Plan to pay for the evaluation and management service. You say that the enrollee was not
enrolled in hospice on the date of service. The Plan denied your request. The Plan says the enrollee's claim
would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the
date of election until the last day of the month in which hospice is revoked. The Plan also says it is the
provider's responsibility to verify the member's coverage before rendering services and to know proper billing
procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on November 11, 2020. The service in question was provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital
care provided on November 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and an intraoral periapical radiographic image (D0220) provided on December 15, 2020.
You asked the Plan to pay for a limited oral evaluation, and an intraoral periapical radiographic image. You say that you thought these services would be covered. The Plan denied your request. The Plan says these services are a covered benefit, but you have exceeded the frequency limits.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, and an intraoral periapical radiographic image have not been met. Specifically, the record shows that you had exceeded the frequency limit for a limited oral evaluation prior to this service on March 7, 2020, and June 22, 2020. The record also shows that you had exceeded the frequency limit for the intraoral periapical radiographic image. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and an intraoral periapical radiographic image (D0220) provided on December 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 28, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 28, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost share for the paravertebral facet joint injections (64493) provided on November 10, 2020.
You asked the Plan to adjust the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the service provided.
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 $750 yearly deductible. After the deductible is met, you pay a $125 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. You have been asked to pay $146.64 which includes a $125 copayment for the outpatient surgery and $21.64 for the amount remaining to meet your yearly deductible. 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 adjust the cost share for the paravertebral facet joint injections (64493) provided on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation visit and injection of Fluid Flow.
You asked the Plan to pre-approve visit for Fluid Flow. You say that this procedure has been covered by Medicare in the past. The Plan denied your request. The Plan says this procedure is experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve visit for Fluid Flow. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found high quality medical studies show that using specific amniotic membrane products may be useful for treating diabetic ulcers in some cases, specific eye conditions, or a disorder known as Stevens-Johnson syndrome. Using amniotic membrane for other conditions or using amniotic fluid products is considered unproven and investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of visit for Fluid Flow have not been met. Therefore, we decided that the Plan does not have to pre-approve a consultation visit and injection of Fluid Flow.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the tympanometry and reflex threshold measurements (92550), the comprehensive hearing test (92557), and the hospital outpatient clinic visit (G0463) provided on July 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the requested services. You say that the services provided were needed for the patient's care. The Plan denied your request. The Plan says the requested services were received out-of-network, and the enrollee did not obtain a referral for out-of-network 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 the tympanometry and reflex threshold measurements (92550), the comprehensive hearing test (92557), and the hospital outpatient clinic visit (G0463) provided on July 30, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for PT and an evaluation provided on November 6, 2020.
You asked the Plan to waive the copayments for PT and an evaluation. You say that you disagree with the additional $35 charge. 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 for outpatient rehabilitation services. A separate copayment applies to the initial evaluation and any re-evaluations. You received PT on November 6, 2020. Therefore, you are responsible to pay the $35 copayment. You received an evaluation on November 6, 2020. Therefore, you are responsible to pay the $35 copayment. The total amount you owe is: $70. You have been asked to pay the total copayment amount of $70 for PT and an evaluation. PT and an evaluation fall within the outpatient rehabilitation 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 copayments for PT and an evaluation provided on November 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventative procedure, by report (D1999) provided July 8, 2020.
You asked the Plan to pay for the unspecified preventative procedure. You say that your dental cleanings should be covered. The Plan denied your request. The Plan says unspecified preventative procedures are not covered under your dental benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified preventative procedure, by report (D1999) provided July 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on December 9, 2020, and December 15, 2020 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that these services are Part B, and should be covered and paid. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that there was not a valid authorization on file.
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 subsequent nursing facility care provided on December 9, 2020, and December 15, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided from August 5, 2020, through August 9, 2020.
You asked the Plan to pay for the ambulance services. You say that this was urgently needed services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 5, 2020 to August 9, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided from August 5, 2020, through August 9, 2020.