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

We decided that the Plan does not have to pay for a consultation (D9310) provided on February 8, 2021.You asked the Plan to pay for a consultation. You say that you want the Plan to pay.The Plan denied your request. The Plan says the service at issue is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for a consultation (D9310) provided on February 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110) provided May 18, 2020.

You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does 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 CPT code.

We find that CPT code 97110 is not supported in the medical record. Specifically, the record shows the services were provided in the home setting. There is a more appropriate CPT code to bill for these services (G0151). Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided May 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on October 20, 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 procedure code 22899 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 22899 is unlisted procedure, spine.We find that CPT code 22899 is not supported in the medical record. Specifically, the operative report does not contain documentation of an unlisted spine procedure. 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 October 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a teeth cleaning (D1110) provided on February 2, 2021.

You asked the Plan to pay for a teeth cleaning. You say that this service should be covered. The Plan denied your request. The Plan says you were not enrolled in the optional dental rider on the date of service and therefore, this is not a covered benefit.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for a teeth cleaning (D1110) provided on February 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the psychotherapy provided from September 11, 2020, to December 11, 2020.You asked the Plan to waive the deductible for the out-of-network psychotherapy. You say that the enrollee would not have purchased a health care plan which could not provide the necessary coverage.The Plan denied your request. The Plan says the charges have been applied correctly to the member responsibility as the deductible has not yet been met.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 $1300 deductible for covered medical services from an out-of-network provider. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1300 deductible for covered medical services from an out-of-network provider. This cost sharing is a contractual obligation that had not been met at the time the psychotherapy was received on September 11, 2020 to December 11, 2020.Therefore, we decided that the Plan does not have to waive the deductible for the psychotherapy provided from September 11, 2020, to December 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and bitewing x-rays (D0274) provided on March 16, 2021.

You asked the Plan to pay for the first intraoral periapical x-ray, additional intraoral periapical x-ray, and bitewing x-rays. You say that you believe these x-rays should be covered.The Plan denied your request. The Plan says these services are not covered 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 first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and bitewing x-rays (D0274) provided on March 16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 20, 2020 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 physician services provided on January 20, 2020 by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, bitewing x-rays, topical application of fluoride varnish, resin-based composite, and two simple extractions provided on January 28, 2021 by an OON provider.

You asked the Plan to pay for the periodic oral evaluation, prophylaxis, bitewing x-rays, topical application of fluoride varnish, resin-based composite, and two simple extractions. You say that you would like to appeal these services. The Plan denied your request. The Plan says the enrollee is responsible for any difference between the Maximum Allowable Fee and the amount the provider bills the enrollee for the 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 enrollee is responsible for the coinsurance amounts plus the difference between the billed and allowed amounts for the services having been received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, bitewing x-rays, topical application of fluoride varnish, resin-based composite, and two simple extractions provided on January 28, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 21, 2020 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 September 21, 2020 by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT image capture (D0381) provided on March 8, 2021.You asked the Plan to pay for the cone beam CT image capture. You say that you would like this service to be reconsidered for coverage because it was necessary.The Plan denied your request. The Plan says this service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The only x-rays covered under your plan are bitewings, full mouth x-rays (complete oral series), and intraoral periapical x-rays.Therefore, we decided that the Plan does not have to pay for the cone beam CT image capture (D0381) provided on March 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care visit and debridement provided on February 4, 2021.

You asked the Plan to pay for the wound care visit. You say that these services were ordered as being medically necessary to avoid wound complications. The Plan denied your request. The Plan says Original Medicare is responsible for these services.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the wound care visit and debridement provided on February 4, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services rendered on December 16, 2020.

You asked the Plan to waive the copayment for these services. You say that the charges are unfair. 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 $50 copayment for emergency care.

Review of the file shows that you received ER services on December 16, 2020. You have been asked to pay a $50 copayment for these services. These services fall within the emergency 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 emergency room (ER) services rendered on December 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 15, 2020.You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the test was not ordered by the treating provider.The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met.Therefore, we decided that the Plan does not have to pay for the lab services provided on December 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-emergency ambulance services (A0425, A0428) provided on February 24, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that you were admitted to the emergency room and then the hospital following these ambulance services. You were told that the copayment for the ambulance would be waived if you were admitted to the hospital. The Plan denied your request. The Plan says that regardless of what you understood about your ambulance copayment, the correct amounts are listed in your contract. Emergency room copayments may be waived if you are admitted, but ambulance copayments are due regardless of admission status. This copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $200 copay for Medicare-covered ambulance benefits.

This copay is waived if you are admitted to the hospital. 

You have been asked to pay a $181.75 copayment for the ambulance services. You say that you thought the copay would be waived since you were admitted to the hospital. While it is true that the contract states the copayment will be waived if you are admitted to the hospital, this waiver applies to ambulance rides to the hospital that are then followed by a hospital admission. The record shows that on the date in question, you were discharged from the hospital and transported back to your residence or a care facility. The waiver does not apply in this case. 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 non-emergency ambulance services (A0425, A0428) provided on February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on January 19, 2021.You asked the Plan to pay for the dental services. You say that when you signed up for this plan, you were told that all dental was covered but you would have to pay a portion for a crown. You say that you do not understand why $90 was not paid. You also say that you were in pain and had swelling and redness on your gum.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 January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 25, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator rendered on September 6, 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 there is no valid proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery.

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 neuromuscular stimulator rendered on September 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 7, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.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 July 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on June 9, 2020 by an OON provider.

You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were advised that the provider who rendered these services is a participating provider. The Plan denied your request. The Plan says the treating provider was not a participating provider on this date of 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 covered when they are received OON. The records show that provider in question was approved for network participation on November 9, 2020, several months after services were rendered. The record also shows that no calls were received from the provider or yourself to verify benefits or network participation prior to this date of service. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on June 9, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), the periapical x-ray (D0220), the re-cement of a crown (D2920), and the unspecified preventive service (D1999) provided on December 22, 2020.

You asked the Plan to reimburse you for the dental services. You say that these services were rendered on an emergency basis. You say that your regular in network dentist was not able to see you until January 5, 2021. You also say that the handbook states that in most cases, you will pay for the cost of the service if you see an out of network provider. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services performed out of network are 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, dental services performed out of network are not among those covered under this benefit. The Evidence of Coverage clearly states that supplemental dental services must be received from a participating provider in order to be covered by the plan. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), the periapical x-ray (D0220), the re-cement of a crown (D2920), and the unspecified preventive service (D1999) provided on December 22, 2020.