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

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the
enrollee on January 4, 2021.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We find that Healthcare Common Procedure Coding System code G0483 is not supported in the medical
record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when
the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the
records reflect of place of service of a doctor's office (POS 11). 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 drug testing services (HCPCS G0483) provided to the enrollee on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary (D5820) provided January 4, 2021.
You asked the Plan to pay for the interim partial denture. You say that you were not aware that the service would not be covered. The Plan denied your request. The Plan says this service is 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 interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary (D5820) provided January 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on January 17, 2021, and January 18, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you did not take any self-administered drugs. You also say that you only took laxatives and Advil. The Plan denied your request. The Plan says self-administered drugs are not covered by Medicare.
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 on January 17, 2021, and January 18, 2021.
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 waive the coinsurance for the limited oral evaluation - problem focused (D0140) provided March 18, 2021.
You asked the Plan to waive the coinsurance for the limited oral exam. You say that you did not understand that this provider was out-of-network and you would be subject to different cost-sharing. The Plan denied your request. The Plan says the out-of-network coinsurance was applied correctly.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the limited oral exam at 50% of the billed amount when provided out-of-network.
We looked at the file and Medicare rules. You have been asked to pay $20 ($40 billed amount x 50% coinsurance =$20) for the limited oral exam. This service was provided by an out-of-network provider. Based on this information, we decided that the Plan does not have to waive the coinsurance for the limited oral evaluation - problem focused (D0140) provided March 18, 2021.
Your complaint about not feeling that it was clear that the provider was out-of-network 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lift chair provided on February 9, 2021 to February 10, 2021 by a non-participating 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 a non-participating 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 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 lift chair provided on February 9, 2021 to
February 10, 2021 by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the posterior resin-based composite on tooth #32 provided on
April 1, 2021.
You asked the Plan to pay for the resin-based composite. You say that you were under the impression that
fillings were covered at 100%. You also say that you were not advised that fillings on back teeth would not be
fully covered. The Plan denied your request. The Plan says the claim processed correctly, and the $52
difference remains your financial responsibility.
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, for posterior composite restorations,
the Plan will pay only the amount that it would have paid to restore the tooth with an amalgam. You are
responsible for the difference in cost. Tooth #32 is a posterior tooth. Therefore, we decided that the Plan does
not have to pay for the posterior resin-based composite on tooth #32 provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a gastroenterology telehealth visit provided on March 2, 2021.
You asked the Plan to waive the copayment for specialist visit. You say that this was an unsolicited telehealth call, so you should not be responsible for a copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $40 copayment for each covered specialist telehealth visit.
You have been asked to pay $40 copayment for specialist visit. 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 gastroenterology telehealth visit provided on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided on March 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that your doctor recommended you go to this provider. The Plan denied your request. The Plan says this was not authorized.
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 office visit (99203) provided on March 30, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97110) provided on October 27,
2020.
You asked the Plan to pay for physical therapy services. You say that this was not available from in-network
providers. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that a physical therapist must supervise PTAs.
We looked at the file and Medicare rules. The records show that the services at issue were provided by a PTA,
but do not show that a physical therapist was present to supervise the PTA. Based on this information, we
decided that Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided
that the Plan does not have to pay for physical therapy services (97110) provided on October 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or
established patient (D0180) received March 22, 2021.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that the service you received
on February 23, 2021 should not count as comprehensive. The Plan denied your request. The Plan says your
benefit is limited to one comprehensive evaluation every three years.
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 is only
covered under this benefit for one procedure every three years. The Plan last covered a comprehensive oral
evaluation on February 23, 2021.
When you received the comprehensive periodontal evaluation on March 22, 2021 your benefit was exhausted.
Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or
established patient (D0180) received March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture.
You asked the Plan to pre-approve the upper partial denture. You say that this is necessary and should be covered. The Plan denied your request. The Plan says the enrollee's dental benefit does not cover dentures.
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 an upper partial denture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from February 28 through March 9, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that it is not fair that you were transferred to another hospital. The Plan denied your request. The Plan says if you are transferred from one hospital to another, a new inpatient hospital cost-sharing will be 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 $385 copayment per day for days 1 - 5 for Inpatient Hospital Care. You have been asked to pay a $1,925 copayment ($385 per day for days 1 - 5) for the inpatient hospital stay. The inpatient hospital 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 the inpatient hospital stay from February 28 through March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 24, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services 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 for the services provided by an out-of-network provider on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete lower denture (D5120) and complete upper denture (D5110).
You asked the Plan to pre-approve the dental services. You say that you have to wait one more year for new dentures, but your current dentures are uncomfortable, and your gums have shrunk. The Plan denied your request. The Plan says this request exceeds the plan benefit limitation.
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 health plan contract specifically says that dentures are limited to one set every 5 years. The records show that you received these services June 12, 2017. 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 complete lower denture (D5120) and complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided April 7, 2021.
You asked the Plan to pay for the periapical x-rays. You say that you were not informed there would be a charge for the services. The Plan denied your request. The Plan says this type of x-ray is 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
intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided April 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the pelvis (72192) provided on February 11, 2021.
You asked the Plan to waive the copayment for a CT scan of the pelvis. You say that the Plan's Annual Notice of Changes lists your copayment for the service at issue as $35. 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 $180 copayment for advanced imaging services received at a primary care provider or specialist's office or at a freestanding radiological facility.
You have been asked to pay a $145.46 copayment for a CT scan of the pelvis. A CT scan of the pelvis falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay less than or equal to the full and 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 CT scan of the pelvis (72192) provided on February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87500, 87532,
87541, 87581, 87634, 87640, 87641, 87798) provided on July 29, 2020.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan
denied your request. The Plan says this was not billed with the correct POS.
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 laboratory services have not been met. Therefore, we decided that
the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87500, 87532, 87541, 87581,
87634, 87640, 87641, 87798) provided on July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
December 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services 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 for the services provided by an out-of-network provider on December 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on March 23, 2021.
You asked the Plan to waive the copayment for these services. You say that you did not go to the hospital. The Plan denied your request. The Plan says the copayment was 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 $325 copayment for each Medicare-covered non-surgical visit in an outpatient clinic.
Review of the file shows that you had an outpatient hospital clinic visit on March 23, 2021. Per the contract with the Plan, there is a $325 copayment for each Medicare-covered non-surgical visit in an outpatient clinic. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $135.35. Given that the allowed amount was less than the $325 copayment, you have been asked to pay $135.35 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture provided on January 4, 2021.
You asked the Plan to pay for the maxillary partial denture. You say that you were told this partial denture was authorized through your insurance Plan, but it was not. The Plan denied your request. The Plan says this service is not covered. The Plan also says that the predetermination notice was sent to you on December 30, 2020 and showed that there would be no benefit for a maxillary partial denture (D5213) as the service is not 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.
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 maxillary partial denture provided on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns - porcelain/ceramic (D2740) provided April 1,
2021.
You asked the Plan to pay for the crowns. You say that you would like the crowns to be processed under your
medical benefits. The Plan denied your request. The Plan says this service is not covered under your dental or
medical 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. Additionally, crowns are not among those services covered by
Medicare. Therefore, we decided that the Plan does not have to pay for the crowns - porcelain/ceramic (D2740)
provided April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the thoracolumbosacral orthosis provided on March 24, 2021.
You asked the Plan to pay for the thoracolumbosacral orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation is missing required information.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file shows does not include a valid proof of delivery or a delivery ticket. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the thoracolumbosacral orthosis provided on March 24, 2021.