Persius/hicric huggingface dataset:
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) and unspecified preventive procedure, by report (D1999) provided April 6, 2021.
You asked the Plan to pay for the full mouth x-rays and unspecified preventative procedure. You say that you would like the services covered. The Plan denied your request. The Plan says you have exceeded frequency limits for the full mouth x-rays and the unspecified preventative procedure is not a covered service under your 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. The Plan covers the full mouth x-rays once every 36 months.
We looked at the file and Medicare rules. The Plan provided documentation showing that full mouth panoramic
x-rays were previously covered on August 12, 2020. Based on this information, we determined that the Plan's
frequency limit for full mouth x-rays has been exceeded. Though the Plan offers dental benefits in excess of
Medicare coverage, the unspecified preventative procedure is not among those service covered. Therefore, we
decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210)
and unspecified preventive procedure, by report (D1999) provided April 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428) provided on February 16, 2021.
You asked the Plan to pay for the ambulance service. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 pay for the ambulance service. Our reviewer says that the ambulance service was not medically necessary. Our physician reviewer found that the enrollee is a
59-year-old female who reported chronic shortness of breath and altered mental status. Ambulance services were utilized for transport from home to an outpatient medical office facility. The enrollee is a high fall risk. Other means of transport such as stretcher or wheelchair van were not contraindicated for this non-emergent medical office transportation. The enrollee was not documented to require any special equipment or expertise
during transport. The documentation does not support that the enrollee required ambulance services on
February 16, 2021 or that they were medically reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the ambulance service have not been met. Therefore, we decided that the Plan
does not have to pay for ambulance service, basic life support, non-emergency transport (A0428) provided on
February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from May 11, 2020, to
September 9, 2020.
You asked the Plan to pay for the office visits and applications of a modality. You say that you have been
covered for chiropractic issues in the past. The Plan denied your request. The Plan says these services are
explicitly excluded.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for office visits (99213) and applications of a modality (97012) provided
from May 11, 2020, to September 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewing x-rays, panoramic x-ray, and prophylaxis provided on April 5, 2021 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, panoramic x-ray, and prophylaxis. You say that you were advised that this provider accepted your insurance. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that services are only covered through dentists participating in the Plan's network.
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. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewing x-rays, panoramic x-ray, and prophylaxis provided on April 5, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to cover your coinsurance for services provided from January 3, 2021 to February 26, 2021.
You asked the Plan to cover the dialysis treatment coinsurance. You say you thought you had reached your MOOP and that you did not know your MOOP had increased. The Plan denied your request. The Plan says you were charged the 20% coinsurance correctly and it was applied to your MOOP.
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 20% coinsurance for outpatient dialysis treatment and you have a $2000 maximum out-of-pocket amount for medical services. You have been asked to pay 20% coinsurance for the dialysis treatments. 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. You have not met your MOOP. The coinsurance has been
charged correctly. Therefore, we decided that the Plan does not have to cover your coinsurance for services
provided from January 3, 2021 to February 26, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for emergency care provided on March 6, 2021, and March 9, 2021.
You asked the Plan to waive the copayments for emergency care. You say that the emergency room did nothing to treat your condition and you were in pain. 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 $90 copayment for emergency care. The medical records show that you received emergency care on March 6, 2021, and March 9, 2021. Therefore, you are responsible to pay a $90 copayment per each visit. The total amount you owe is: $180. You have been asked to pay the total copayment amount of $180 for emergency care. Emergency care falls 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 copayments for emergency
care provided on March 6, 2021, and March 9, 2021.
We note your complaint that the emergency room failed to treat your condition. Your complaint is a grievance
that must be answered by the health plan. Medicare does not permit us to make a decision about these types of
complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the drug services rendered on December 10, 2020.
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B covered drugs.
Review of the file hsows that you received Part B drugs on December 10, 2020. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare Part B covered drugs 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 coinsurance for the drug services rendered on December 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 10, 2020.
You asked the Plan to pay for the laboratory services. 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover these
tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services provided on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided by an opted-out provider from January 26, 2021, to February 16, 2021.
You asked the Plan to pay for office services. You say that the original surgery was partially covered, so you are respectfully requesting reconsideration of this denial. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider has opted-out of Medicare and is not payable.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for office services provided by an opted-out provider from January 26, 2021, to February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses (V2025) and sphere lenses (V2100) provided on
February 27, 2021.
You asked the Plan to pay for eyeglasses and sphere lenses. You say that you have been granted a handicap
sticker because of your vision on your last appointment. You also say you would like reconsideration as you
are on a fixed income. The Plan denied your request. The Plan says you are responsible for services received
out-of-network for your frames and lens package.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when they are received from a provider who participates in the Plan's
specified vision network.
We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network.
Based on this information, we decided that the Plan's rules for coverage of eyeglasses and sphere lenses have
not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses (V2025) and sphere
lenses (V2100) provided on February 27, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal aortic aneurysm screening you received on April 27, 2021.
You asked the Plan to pay for the screening. The Plan denied your request. The Plan says this service is covered once per lifetime.
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 $0 copayment for a one-time abdominal aortic aneurysm screening. Review of the file shows that you were provided an abdominal aortic aneurysm screening on April 27, 2021. This screening is only covered once per lifetime. The records show that you had a covered abdominal aortic aneurysm screening on March 16, 2020. This means that the requested screening exceeds the benefit limit and is not covered. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the abdominal aortic aneurysm screening you received on April 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says an IRF admission is 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for sepsis, rhabdomyolysis, NSTEMI and Parkinson's disease. You have been discharged home. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you 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 an IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from January 8, 2021, through February 6, 2021.
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says the enrollee did not meet Medicare coverage criteria for continuation of SNF services.
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 pay for continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on review of the available records, the enrollee did not meet the CMS coverage criteria for continuation of care at a SNF beyond January 7, 2021. The enrollee's main diagnosis is Debility, and the enrollee was medically stable. There are no documented rehabilitation nursing needs. The enrollee made minimal to no progress with skilled therapies from November 25, 2020, to January 6, 2021 and the therapists discharged her recommending long-term care placement. The enrollee did not require daily skilled therapy services on an inpatient basis in a SNF for the dates in question. Continuation of a SNF stay was not medically necessary beyond January 7, 2021. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from January 8, 2021, through
February 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-Ray examination provided on August 7, 2019.
You asked the Plan to pay for X-Ray. You say that the timely filing limit has been waived due to the COVID-19 crisis. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim was not submitted within the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for X-Ray was not filed until April 2, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for an X-Ray examination provided on August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an ankle orthosis provided on March 25, 2021.
You asked the Plan to waive the coinsurance for ankle orthosis. You say that you already paid $7.80 on the date of service and do not think this amount is correct. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for ankle orthosis. The allowed amount of the claim is $97.85, resulting in a coinsurance amount of $19.57. You have been asked to pay 20% coinsurance for ankle orthosis. Ankle orthosis falls within the Prosthetic Devices and Related 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 coinsurance for an ankle orthosis provided on March 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient diagnostic imaging rendered on January 14, 2021.
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the coinsurance 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 50% of the total cost for out-of-network Medicare-covered diagnostic radiology services.
Review of the file shows that you received an ultrasound on January 14, 2021. You have been asked to pay 50% of the total cost for these services. These services fall within the out-of-network Medicare-covered diagnostic radiology 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 coinsurance for the outpatient diagnostic imaging rendered on January 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) and unspecified preventive procedure, by report (D1999) provided February 23, 2021.
You asked the Plan to pay for the fluoride varnish and unspecified preventative procedure. You say that you only wanted services covered by the Plan and you were dissatisfied with the services. The Plan denied your request. The Plan says these services are not covered under the enrollee's 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
topical application of fluoride varnish (D1206) and unspecified preventive procedure, by report (D1999) provided February 23, 2021.
Your complaint about which services are covered and the provider's billing procedures 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 complete series of intraoral x-rays (D0210) and panoramic x-ray (D0330) provided on April 14, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays and panoramic x-ray. You say that the dentist you normally go to referred you to another dentist. You also say that you are on a fixed income. The Plan denied your request. The Plan says benefits for these services have 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, complete series of intraoral x-rays (D0210) and panoramic x-ray (D0330) share a frequency limit and are limited to one procedure code every
three years. The record shows that you received a panoramic x-ray on June 15, 2020 and your full mouth or panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) and panoramic x-ray (D0330) provided on April 14, 2021.