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

We decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider on September 1, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you were transported from one facility to a different facility. You say that no one discussed the financial responsibility that this would require. 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 $220 copayment for ambulance services. You have been asked to pay a $220 copayment for ambulance services. The correct copayment has been applied to the services that were provided. Ambulance services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider on September 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the gene panel provided on June 9, 2020.
You asked the Plan to pay for the services provided. You say that the test performed is valid with the procedure
codes and diagnosis submitted. The Plan denied your request. The Plan says the place of service must reflect
the location of the enrollee when the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We looked at the file and the rules. The records provided do no indicate the enrollee's lab sample was taken at
an independent laboratory. Based on this information, we decided that Medicare rules for coverage of the
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the gene panel
provided on June 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services.

You asked the Plan to pay for the critical care services. You say that the claim was submitted timely, but the enrollee gave incorrect insurance information. The Plan denied your request. The Plan says the claim was untimely.

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 the physician services was not filed until December 22, 2020. 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 critical care services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization.
You asked the Plan to pre-approve parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a mildly elevated ionized calcium and normal parathyroid hormone level. A neck ultrasound shows thyroid nodules only. In this case a single calcium determination has been performed. The enrollee is receiving vitamin D therapy. The surgical plan is not documented. The medical reasonableness and necessity of the requested service is not demonstrated by the provided documentation. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization have not been met. Therefore, we decided that the Plan does not have to pre-approve parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services that you provided on
October 21, 2020.
You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says prior authorization from the Plan is required in advance of obtaining out-of-network services. The only exceptions are if the service is either urgent or emergent or if the specialized service is not available within the Plan's network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 ophthalmological services that you provided on
October 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the dental services that you received from January 29, 2020, to November 4, 2020.
You asked the Plan to reimburse you for the dental services. You say that you do not understand why the full amount of your 2019 dental cost and this year (2020) are denying reimbursement for the providers being out of network. You say that you understand that you have a reimbursement maximum of $1,000. You say that due to your out of pocket expenses being greater than your allowance, you believe you should be reimbursed the full amount. You also say that your dental provider is good and are not interested in changing providers. The Plan denied your request. The Plan says there is a $1,000 allowance for covered dental services. The Plan also says that the allowance has been exhausted.
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 $1,000 allowance has been exhausted. The record shows that the Plan paid $167 towards dental services that you received on August 4, 2020, and $833 towards dental services that you received on November 10, 2020. The Evidence of Coverage says that you are responsible for any amount above the dental coverage limit. Additionally, out of network providers may bill you for the difference between what they bill you and what the plan pays. Therefore, we decided that the Plan does not have to reimburse you for the dental services that you received from January 29, 2020, to November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided on
April 28, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says payment for
the services is included in the payment to the facility.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility for services furnished to a beneficiary.
We looked at the file and the rules. The facility must furnish all necessary covered services to the beneficiary
either directly or under arrangements made with outside providers. This service was provided via arrangement
of the facility. Payment for this service would have been included under the facility claim. Payment to you for
this service is the responsibility of the facility. Therefore, we decided that the Plan does not have to pay for the
intraoperative neuromonitoring services provided on April 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the admission to a skilled nursing facility (SNF) admission
provided from October 23, 2020, to November 21, 2020.
You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare
Act. The Plan denied your request. The Plan says the enrollee did not require any skilled nursing or therapy
services during the dates of service in this case. The Plan also says that custodial care is not covered.
The Plan must follow Medicare rules. Custodial care is not covered.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for
the admission to a skilled nursing facility (SNF) admission provided from October 23, 2020, to November 21,
2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care.

You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 copayment for emergency care.

You have been asked to pay a $120 copayment 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 copayment for emergency care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the clinic service and emergency treatment of dental pain provided on November 30, 2020.
You asked the Plan to pay for the clinic service and emergency treatment of dental pain. You say that you would like these services to 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 clinic service and emergency treatment of dental pain provided on November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a teeth cleaning (D1110) provided on October 1, 2019.
You asked the Plan to pay for a teeth cleaning. You say that you want to be reimbursed for this service. The Plan denied your request. The Plan says your benefit maximum was exceeded for this 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. The Plan allows two teeth cleaning per calendar year. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of teeth cleaning have not been met. Specifically, the record shows that you received teeth cleanings on January 16, 2019, and on May 21, 2019. Therefore, we decided that the Plan does not have to pay for a teeth cleaning (D1110) provided on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 6, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician's services provided on October 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Arthrocentesis.

You asked the Plan to waive the copayment for Arthrocentesis. You say that you disagree with how the charges were billed. 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 $325 copayment for outpatient surgery, including services provided at hospital outpatient facilities.

You received Arthrocentesis at an outpatient hospital facility. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $259.29, which is less than the $325 copayment.

You have been asked to pay $259.29 for Arthrocentesis. Arthrocentesis falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for Arthrocentesis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chiropractic services provided by a participating provider on October 1, 2020, to October 8, 2020.
You asked the Plan to waive the copayment for chiropractic services. You say that you do not agree with these copayments. 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 $20 copayment for chiropractic services. You have been asked to pay a $20 copayment for chiropractic services. The total amount you are being asked to pay is $60 ($20 x 3 chiropractic visits = $60). Chiropractic services fall within the chiropractic 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 chiropractic services provided by a participating provider on October 1, 2020, to October 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing rendered on July 7, 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, a respiratory pathogen panel, was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not
have to pay for the genetic testing rendered on July 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen equipment.

You asked the Plan to pay for the oxygen equipment. You say that you would like reconsideration because you were not able to see your primary care physician and you are requesting the allowable out-of-network cost to be reimbursed to you. The Plan denied your request. The Plan says the purchase of oxygen equipment is not allowed and you did not receive this equipment from a Medicare Certified provider.

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. The rules also say that payment is not made for purchases of oxygen equipment.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Additionally, only rentals of oxygen equipment are allowed. Therefore, we decided that the Plan does not have to pay for oxygen equipment.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation of portable x-ray equipment and personnel to home or nursing home (R0070) provided September 14, 2020.
You asked the Plan to pay for the diagnostic services. You say that this service was of medical necessity. as a mobile physician office outfitted with x-ray equipment, you meet the requirement of transporting x-ray equipment to the location where services were performed. The Plan denied your request. The Plan says the place the service inappropriate for the procedure.
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 R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location. We find that CPT code R0070 is not supported in the medical record. Specifically, CPT code R0070 is a technical component only code, it should be reported on a hospital setting. However, the enrollee was not in a skilled nursing facility as a result provider should bill POS 32 for the services to be covered. Based on this information, we decided that Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for transportation of portable x-ray equipment and personnel to home or nursing home (R0070) provided September 14, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided out of network on February 17, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says these services are not covered by Medicare.
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 is not a Medicare eligible provider. A licensed marriage family therapist is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for outpatient mental health care provided out of network on February 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 10, 2020, and September 23, 2020.
You asked the Plan to pay for the lab services. You say that you were not told the lab was out-of-network. The Plan denied your request. The Plan says the claim processed 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 there is a $350 deductible. The file shows that lab services were provided by an out-of-network provider. The lab services fall within the benefit category outpatient diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $350 deductible. This cost sharing is a contractual obligation that had not been met at the time the lab services were received. Therefore, we decided that the Plan does not have to pay for the lab services provided on September 10, 2020, and September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty to allow for restorative
procedure, per tooth, (D4212) provided on November 12, 2020.
You asked the Plan to pay for the dental service. You say that you had cancer. You say that your bones,
including your teeth, were weakened due to the radiation treatment you received. You say that you had to have
the roof of your mouth removed and an obturator put in. You say that was supported by the new crown that you
got. You also say that without the obturator, you would be unable to eat, drink, or speak. The Plan denied your
request. The Plan says gingivectomy or gingivoplasty is not listed as a covered service. The Plan also says that
any services not listed 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, 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
gingivectomy or gingivoplasty to allow for restorative procedure, per tooth, (D4212) provided on November
12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for COVID-19 testing.

You asked the Plan to pay for the COVID-19 testing. You say that you would like reconsideration because this testing was requested by your provider and should be covered. The Plan denied your request. The Plan says this is not a covered benefit.

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 test at issue in this appeal, the COVID-19 testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the record does not indicate that this testing was performed with relationship to treatment or diagnosis for a specific illness, symptom or complaint. Therefore, we decided that the Plan does not have to pay for COVID-19 testing.