Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on November 16, 2020.
You asked the Plan to waive the copayment for the endoscopy. You say that you never had a copayment for an endoscopy. 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 $350 per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. You have been asked to pay a $350 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 endoscopy provided on November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the interrogation device evaluation provided on October 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the interrogation device evaluation. You say that the service was medically necessary. 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 interrogation device evaluation provided on October 23, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection provided on July 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an injection. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the referring provider is out-of-network.
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 an injection provided on July 7, 2020 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 1-surface fillings (D2391) for teeth # 2 and 3, the 2-
surface filling (D2392) for tooth # 32, and the 3-surface filling (D2393) for tooth # 29 provided on January 4,
2021.

You asked the Plan to pay for the dental services. You say that this dentist is in network. You say that you have
been using this dentist's services for the past 13 years while your employer provided you with dental coverage.
The Plan denied your request. The Plan says fillings are not listed as covered services.

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. Additionally, dental services performed out of network are not
covered. Therefore, we decided that the Plan does not have to pay for the 1-surface fillings (D2391) for teeth #
2 and 3, the 2-surface filling (D2392) for tooth # 32, and the 3-surface filling (D2393) for tooth # 29 provided
on January 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on December 28, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that you are on a fixed income and cannot afford 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 $350 copayment for ambulance services. 

You have been asked to pay a $350 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on December 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services. The Plan denied your request. The Plan says based on the enrollee's current medial stability and lack of medical complexity IRF services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingival irrigation (D4921) and the localized delivery of antimicrobial agents (D4381) provided on January 8, 2021.
You asked the Plan to pay for the dental services. You say that you contacted the Plan to get the name of in network dental providers. You say that you would not have known if the provider was a network provider. You also say that you should not be held responsible for this claim. The Plan denied your request. The Plan says gingival irrigation is not listed as a covered service. The Plan says that localized delivery of antimicrobial agents 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 gingival irrigation (D4921) and the localized delivery of antimicrobial agents (D4381) provided on January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on December 3, 2020.

You asked the Plan to pay for the laboratory services. You say that the patient does not come to the lab, the participating doctor sends the specimens to process. You say that the cost of the test, lab equipment and technicians is expensive, and you cannot afford for claims to be unpaid. The Plan denied your request. The Plan says prior authorization was required but 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 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 laboratory services provided by an out-of-network provider on December 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee on August 23, 2020.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the service was billed with an inconsistent place of service.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, these services were billed with place of service 31 (skilled nursing facility). The place of service billed with this code is not consistent with a home health place of service. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee on August 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from December 18, 2020, to December 22, 2020.
You asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says self-administered drugs are not covered under the enrollee's Part C benefits.
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 pay for the self-administered drugs provided from December 18, 2020, to December 22, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5257) purchased on December 9, 2020.
You asked the Plan to pay for the hearing aids. You say that the provider told you that you were covered for $2,500 per ear and you would not have made this purchase if you knew they would not be covered. The Plan denied your request. The Plan says hearing aids are only covered when they are received from the Plan's specified hearing vendor. You purchased your hearing aids from a different provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are purchased from the Plan's specified hearing vendor. Hearing aids order through other providers are not covered. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5257) purchased on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 4, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you were told that you could use the specialist as your primary care physician. 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 specialist visits. You have been asked to pay a $30 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 for a specialist visit provided on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement (11044) provided on September 2, 2020.
You asked the Plan to pay for the debridement. You say that you would like reconsideration because the surgeon believed the services of an assistant-at-surgery were medically necessary. The Plan denied your request. The Plan says the services of an assistant surgeon, co-surgeon or surgical team are not covered for this service.
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 Current Procedural Terminology (CPT) code 11044. 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 have not been met. Therefore, we decided that the Plan does not have to pay for the debridement (11044) provided on September 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the abdomen; without contrast (74181) provided on January 26, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment 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 $250 per day for other Medicare-covered diagnostic radiology services that are not ultrasounds. You have been asked to pay $245.08 for the Medicare-covered diagnostic radiology service provided. This amount is less than the applicable copayment for this 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 waive the copayment for the magnetic resonance imaging (MRI) of the abdomen; without contrast (74181) provided on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical radiographic images (D0230 x2) provided on January 25, 2021.
You asked the Plan to pay for intraoral periapical radiographic images. You say that you were told that this provider was in-network and you want the Plan to pay for the services. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every year.
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 intraoral periapical radiographic images have not been met. Specifically, the record shows that you had exceeded the frequency limit for this service. Therefore, we decided that the Plan does not have to pay for intraoral periapical radiographic images (D0230 x2) provided on January 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for services provided from September 11, 2020, to December 18, 2020.
You asked the Plan to waive the cost share for the office visits, skilled nursing facility services, emergency services, continuous glucose monitor supplies, and labs. You say that you met your out of pocket maximum in January 2020. The Plan denied your request. The Plan says after an audit and a reduction in payment for services, you had $485.39 left to be met toward your in-network out-of-pocket maximum.
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 have a $2100 maximum out of pocket for in-network covered medical services. You have been asked to pay cost share for the office visits, skilled nursing facility services, emergency services, continuous glucose monitor supplies, and labs. The Plan made an adjustment of the overpayment for your inpatient stay. This reduction left the MOOP not met, and cost-shares were then applied for the services. 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 cost share for services provided from September 11, 2020, to December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental surgery procedure (41899) and anesthesia for intraoral procedure (00170).
You asked the Plan to pre-approve the dental surgery procedure and anesthesia for intraoral procedure. The Plan denied your request. The Plan says the enrollee does not meet the criteria for Medicare's dental inclusion.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a dental surgery procedure (41899) and anesthesia for intraoral procedure (00170).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5261) provided February 5, 2020.
You asked the Plan to pay for the hearing aids. You say that this hearing provider provided quality hearing aids at a better rate than the Plan's hearing vendor's exclusive provider and should be covered. The Plan denied your request. The Plan says hearing aids provided by a non-contract provider are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids up to the maximum benefit when purchased from the Plan's hearing vendor's exclusive hearing provider. We looked at the file, and the Plan's rules. You did not purchase hearing aids from the Plan's hearing vendor's exclusive hearing provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) provided February 5, 2020.
Your complaint about the cost of hearing aids from the hearing vendor's provider 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided December 16, 2020.
You asked the Plan to pay for the complete series of x-rays. You say that you are entitled to bitewing x-rays and believe your x-rays should be covered. The Plan denied your request. The Plan says the complete series of x-rays is not a covered service 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 intraoral - complete series of radiographic images (D0210) provided December 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a colonoscopy (45380) provided on December 28, 2020.
You asked the Plan to waive the coinsurance for a colonoscopy. You say that you met your deductible ans should not be charged. The Plan denied your request. The Plan says this 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 that after the yearly deductible is met, you must pay a 10% coinsurance for outpatient surgery. You have been asked to pay a $95.42 coinsurance for a colonoscopy ($954.15 allowed amount x 10% = $95.42, rounded to the nearest cent). 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 coinsurance for a colonoscopy (45380) provided on December 28, 2020.