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

We decided that the Plan does not have to pay for the chest x-ray rendered on April 10, 2021.
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 billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that inpatient claims must be billed with POS code
21.
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the
date of service at issue and the claim was not billed with the required POS code 21. Based on this information,
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on April 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a rest home visit (99336) provided on February 19, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for a rest home visit. You say that the nursing home should have obtained authorization. The Plan denied your request. The Plan says this service 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 a rest home visit (99336) provided on February 19, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided by a participating provider on February 16, 2021.

You asked the Plan to waive the copayment for wound care. You say that this wound has never healed. You say that you would like this copayment waived. The Plan denied your request. The Plan says the correct copayment has been 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 $250 copayment for outpatient surgery/outpatient surgery. 

You have been asked to pay a $250 copayment for wound care. The correct copayment has been applied to the services that were provided. Wound care is considered an outpatient surgery. Wound care falls within the outpatient surgery/outpatient surgery 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 wound care provided by a participating provider on February 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from February 19,
2021, to February 21, 2021.

You asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says selfadministered
drugs are not covered.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 February 19, 2021, to February 21, 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound (76641) provided
March 11, 2021.

You asked the Plan to waive the copayment for the diagnostic services. You say that an ultrasound is not listed
as a diagnostic radiology service on the summary of benefits and you feel that the provider might have billed
wrong. The Plan denied your request. The Plan says the claim was processed with the correct copayment
applied per the Evidence of Coverage.

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 $110
copayment for Medicare covered diagnostic radiology services.

You have been asked to pay $110 copayment for the diagnostic service. The diagnostic service falls within the
Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the breast ultrasound (76641) provided March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 20, 2021 by an out-of-network
(OON) provider.

You asked the Plan to pay for the office visit. You say that you feel these services should be covered. The Plan
denied your request. The Plan says the services rendered are not a covered benefit.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 office visit provided on January 20, 2021 by an
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 9, 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 office visit provided on March 9, 2021 by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided by an out-ofnetwork
provider on February 9, 2021.

You asked the Plan to waive the deductible for an office visit. You say that you do not agree with this being
denied. The Plan denied your request. The Plan says the correct deductible amount has been applied.

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 there is a $1,500 deductible for physician/practitioner services.

The item or service you asked the Plan to waive the deductible for falls within the benefit category
physician/practitioner services. The Plan has followed Medicare rules by clearly disclosing in the contract that
there is a $1,500 deductible for physician/practitioner services. This cost sharing is a contractual obligation that
had not been met at the time an office visit was received on February 9, 2021. The total amount you are being
asked to pay is $94.06. Therefore, we decided that the Plan does not have to waive the deductible for an office
visit provided by an out-of-network providers on February 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery provided on February 22, 2021.

You asked the Plan to waive the copayment for outpatient surgery. You say that this was an office visit and not surgery. 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 $250 copayment for outpatient surgery at an outpatient hospital. 

You have been asked to pay $250 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery and Other Medical 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 outpatient surgery provided on February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2393) provided on March 25, 2021.

You asked the Plan to pay for the resin-based composite. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the resin-based composite you received is not covered under the Plan's supplemental dental 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 resin-based composite you received is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2393) provided on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on August 13, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid.

In this case, the MUE for CPT code 11047 is 1. You billed 2 units of this code, exceeding the MUE. Based on
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore,
we decided that the Plan does not have to pay for the surgical services rendered on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the extractions, removals of residual tooth roots, and alveoloplasties in conjunction with extractions provided on December 31, 2020 by an OON provider.

You asked the Plan to pay more for the extractions, removals of residual tooth roots, and alveoloplasties. You say that you were assured that the treating provider was in-network. You also say that the enrollee was not advised until the day of the surgery that the initial in-network provider the enrollee had seen was not available to treat the enrollee. The Plan denied your request. The Plan says these services were performed by a non-participating provider, and the enrollee is responsible for any difference between the Maximum Allowable Fee and the amount the provider bills the enrollee for the services. The Plan also says that the enrollee's oral surgery benefit has been satisfied and the frequency limitation has been exceeded.

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 enrollee is responsible for a 55% coinsurance for each extraction and a 75% coinsurance for each oral surgery that is received by an OON provider. The contract also states that the enrollee may be billed more for services that are received OON. The contract says that oral surgery is limited to two procedures per calendar year. The record shows that the enrollee received three removals of residual tooth roots, two of which were covered by the Plan at the OON benefit rate, and the enrollee's oral surgery benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the extractions, removals of residual tooth roots, and alveoloplasties in conjunction with extractions provided on December 31, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional mileage for routine transportation.

You asked the Plan to provide additional mileage. You say that you need to see your provider for treatment,
and you were advised when you signed up with the Plan your rides to the doctor would be covered. The Plan
denied your request. The Plan says each one-way trip must not exceed 50 miles of driving distance.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation when each one-way trip must not exceed 50 miles of driving
distance.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the
Plan does not have to provide additional mileage for routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on March 12, 2021
and March 15, 2021.

You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided
on March 12, 2021 and March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider
on March 10, 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 to you by an out-of-network provider on
March 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance transportation
(A0428-HN, A0425-HN) provided on March 24, 2021.

You asked the Plan to waive the copayment for non-emergency ambulance transportation. You say that you
want the Plan to pay for the services. 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 $290
copayment for ambulance services.

You have been asked to pay a $290 copayment for non-emergency ambulance transportation. The services at
issue 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 non-emergency ambulance transportation (A0428-HN, A0425-HN) provided on March 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 60 additional trips for routine transportation.

You asked the Plan to pre-approve additional routine transportation. You say that you are unable to attend therapy due to not having transportation. The Plan denied your request. The Plan says you have exceeded your benefit limit, and there, this request is not covered by your health plan.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve the 60 additional trips for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental consultation, the dental therapeutic parenteral drugs, and the dental supplies/materials provided from January 7, 2021 to February 2, 2021.

You asked the Plan to pay for the dental consultation, the dental therapeutic parenteral drugs, and the dental supplies/materials. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says they have partially overturned their decision and will pay for the conscious sedation and extraction provided to you. However, the remaining services you received are not covered under the Plan's supplemental dental 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 consultation, the therapeutic parenteral drugs, and the supplies/materials are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental consultation, the dental therapeutic parenteral drugs, and the dental supplies/materials provided from January 7, 2021 to February 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 24, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. 

We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Medicare records from the ordering provider were not submitted. 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 24, 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 9, 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 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on March 12, 2021 and March 15, 2021.

You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on March 12, 2021 and March 15, 2021.