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

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were told you did not have to pay anything for the services because the ambulance did not take you anywhere. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 28, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided on January 17, 2020.You asked the Plan to pay forthe dental services. You say that  The Plan denied your request. The Plan says that you do not have out-of-network coverage.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 says that you pay 100% for covered dental services provided out-of-network.We looked at the file and Medicare rules.The file indicates you received these services from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the dental serviceshave not been met. Therefore, we decided that the Plan does not have to pay forthe dental services provided on January 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient mental health stay from September 4, 2019 to September 12, 2019.You asked the Plan to waive the copayment for an inpatient mental health stay. 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 $220 copayment per day for days 1-7 for inpatient mental health care. You had an inpatient mental health stay from September 4, 2019 to September 12, 2019. Therefore, you are responsible to pay a $220 copayment for days 1-7 (September 4, 2019 to September 10, 2019). $220 (copayment) x 7 (inpatient days) = $1,540.You have been asked to pay the total copayment amount of $1,540 for an inpatient mental health stay. An inpatient mental health stay falls within the inpatient mental health 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 an inpatient mental health stay from September 4, 2019 to September 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens (V2781) Polarization, any lens (V2762) lens (V2783) scratch resistant coating (V2760) provided March 2, 2020. You asked the Plan to pay for the vision services. You say that it is your understanding that you are entitled to receive a benefit in the amount of $220 for routine eyewear. The provider assured you that you were eligible.The Plan denied your request. The Plan says the claim processed and paid according to the plan benefits. 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 any amount above the $220 allowance. You have been asked to pay $680. The plan has paid the $220 allowance. Any amount above the allowance is your responsibility. The vision services fall within the Vision 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 pay for progressive lens (V2781) Polarization, any lens (V2762) lens  (V2783) scratch resistant coating (V2760) provided March 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on August 10, 2019.
You asked the Plan to waive the copayment for the MRI. You say that you weren't asked to pay a fee when you went to get the MRI. You say that you weren't informed there would be a copayment. The Plan denied your request. The Plan says the copayment 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 $215 for other outpatient diagnostic tests. Covered services include magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET). You have been asked to pay a $215 copayment for the MRI. The MRI 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 MRI provided on August 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on October 11, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you had already received an Explanation of Benefits that said you had a $0 copayment. You say you are in a low income situation. The Plan denied your request. The Plan says your claim had originally been denied but has been reprocessed to reflect the correct cost sharing 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 $60 copayment per visit for hyperbaric oxygen therapy; sleep studies; CT scans, MRAs, MRIs, and PET scans. You have been asked to pay a $60 copayment for the CT scan. The CT scan 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 CT scan provided on October 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and clinical crown lengthening provided on January 22, 2019.
You asked the Plan to pay for the first intraoral periapical x-ray and clinical crown lengthening. You say that you think that the Plan should pay at least a percentage of the bill. 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 and clinical crown lengthening provided on January 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medications provided on August 15, 2019. You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the documentation does not include a valid physician order for the billed medication. The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation. We find that CPT codes J2274 and J1170 are not supported in the medical record. Specifically, there is no documentation of a physician order for the services at issue. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the medications provided on August 15, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on June 20, 2019.
You asked the Plan to pay for the chest x-ray. You say that the enrollee was not enrolled in hospice on this date of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on June 12, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on June 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames and lenses purchased January 20, 2020.
You asked the Plan to pay for the vision services. You say that you were unable to find a network provider. You knew they were out of network so you filled out the form provided by the plan. There is no reason for the denial as you followed all guidelines. The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.
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 provided by a network provider. There is no coverage when provided out of network.
We looked at the file and the Plan's rules. You must use an in-network provider for routine coverage including; routine exam, retinal imaging and eyewear allowance. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for frames and lenses purchased January 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the guided tissue regeneration, bone replacement graft for ridge preservation, extraction, and two endosteal implants provided by an OON provider on January 9, 2020.You asked the Plan to pay more for the guided tissue regeneration, bone replacement graft for ridge preservation, extraction, and two endosteal implants. You say that the Plan should pay an 80% share of the surgical procedures and care you received.The Plan denied your request. The Plan says the treating provider is out-of-network with your plan and you were correctly charged a 50% coinsurance. The Plan also says that you had exhausted your annual maximum benefit 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, there is a $1,000 annual maximum per calendar year for comprehensive dental care services. The contract says that you are responsible for any amounts beyond the benefit limits. The Plan contract also says that you must pay a 50% coinsurance for comprehensive dental services that are received by an out-of-network provider. The record shows that you were charged correctly at a 50% coinsurance for each service until you met the annual maximum benefit on January 9, 2020, and your annual maximum benefit was then exhausted. The contract clearly states that out-of-network dental providers may bill you for any charges remaining over the allowed amount for all dental covered services.Therefore, we decided that the Plan does not have to pay more for the guided tissue regeneration, bone replacement graft for ridge preservation, extraction, and two endosteal implants provided by an OON provider on January 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Levofloxacin tablets provided on December 15, 2019.
You asked the Plan to pay for the Levofloxacin tablets. You say that you feel the cost of these 3 pills is excessive. The Plan denied your request. The Plan says this drug is a self-administered drug. The Plan also says this drug is not Part B covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Levofloxacin tablets provided on December 15, 2019.
Benefits for the Levofloxacin tablets 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for LTACH services. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee is not medically stable because she still requires the help of a breathing machine. The Plan says that the enrollee needs to stay in the hospital until she is better.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH), having presented with altered mental status then suffering an immediate cardiac arrest. The enrollee was transiently intubated/ventilated, but is no longer intubated/ventilated. The enrollee was started on hemodialysis for new renal failure. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the ambulance personnel did not deem it necessary that the enrollee be transported, so the enrollee should not be penalized for following these instructions. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 16, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral exam (D0120) x-ray (D0220) fluoride treatment (D1208) periodontal maintenance (D4910) osseous surgery (D4260) biologic material to aid in soft and osseous tissue regeneration (D4265) and anesthesia (D9215) provided February 18, 2019 to December 17, 2019.
You asked the Plan to pay for the dental services. You say that you were told by a plan representative that any dentist of choice can be used for dental services as long as they are licensed. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider.
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. Dental services must be provided by an in-network dental provider. 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 oral exam (D0120) x-ray (D0220) fluoride treatment (D1208) periodontal maintenance (D4910) osseous surgery (D4260) biologic material to aid in soft and osseous tissue regeneration (D4265) and anesthesia (D9215) provided February 18, 2019 to December 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you want to avoid surgery. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies provided on February 6, 2018.
You asked the Plan to pay for diagnostic tests. You say that timely claim filing was not possible for you, and you are requesting an exception for coverage. The Plan denied your request. The Plan says the denial of payment for these services 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 diagnostic tests was not filed until January 13, 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 nerve conduction studies provided on February 6, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on January 14, 2020. You asked the Plan to waive the deductible for the office visit. You say that you weren't informed of the deductible. You say that you're going to have to change plans if the bill isn't taken care of. The Plan denied your request. The Plan says the copayment 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 your deductible is $400. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services. Until you have paid the in-network deductible amount, you must pay the full cost of your covered in-network services. The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $400 deductible applies to office visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on January 14, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on April 7, 2016.
You asked the Plan to pay for drug test. You say that this claim was originally submitted within the timely filing limit. 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 drug test was not filed until December 30, 2019. 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 drug testing provided on April 7, 2016.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a vascular duplex ultrasound study provided on February 4, 2020.
You asked the Plan to pay for the vascular duplex ultrasound study. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 a vascular duplex ultrasound study provided on February 4, 2020.