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

We decided that the Plan does not have to pay more forthe extraction (code D7210), alveoloplasty (code D7210), and extractions (code D7140 x8) provided on July 22, 2019.You asked the Plan to pay more forthe extractions and alveoloplasty. You say that you paid out of pocket for these services. You also say that the tooth extractions were necessary due to your health.The Plan denied your request. The Plan says the services exceed the benefit limit.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, contract specifically says that you have a $250 allowance every year and you are responsible for any amount above the dental coverage limit. The record shows that the Plan paid $97.00 for your claim on June 14, 2019 and the Plan paid $110.00 for another claim on May 16, 2019. The remaining $43.00 was applied to the services provided on July 22, 2019, exhausting your $250 allowance.Therefore, we decided that the Plan does not have to pay more forthe extraction (code D7210), alveoloplasty (code D7210), and extractions(code D7140 x8) provided on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided by the provider on August 20, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that you did not see a specialist.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 $50 copayment for specialist visits. You have been asked to paya $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 fora specialist visit provided on August 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ambulance trip provided by the provider on September 9, 2019.You asked the Plan to waive the copayment foran ambulance trip. You say that the plan was supposed to pay 80% coinsurance.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 ambulance services. You have been asked to pay a $325 copayment for an ambulance trip. An ambulance trip falls 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 foran ambulance trip provided on September 9, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 17, 2019.You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the provider did not submit progress notes that are needed in order to determine the clinical utility of the testing.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.Therefore, we decided that the Plan does not have to pay for the lab services provided on June 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen supplies provided from June 21, 2019 to September 21, 2019.
You asked the Plan to waive the coinsurance for the portable oxygen contents. You say that the coinsurance is calculated incorrectly. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment. You have been asked to pay 20% coinsurance for the oxygen supplies. The oxygen supplies fall within the durable medical equipment 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 oxygen supplies provided from June 21, 2019 to September 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hip x-ray provided on August 14, 2019.You asked the Plan to waive the copayment for the hip x-ray. You say that this was done at your primary care physician's office. 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 a $45 copayment for basic radiological services at an in-network specialist's office or freestanding radiological facility.You have been asked to pay $41.63, which is less than the standard $45 copayment for the hip x-ray. The hip x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the x-ray was performed by a specialist. 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 hip x-ray provided on August 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided by "the provider" on August 27, 2019.You asked the Plan to waive the copayment forlaboratory services. 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 $70 copayment for lab services provided in an outpatient hospital facility. You received lab services at an outpatient hospital facility on August 27, 2019. Therefore, you are responsible to pay the $70 copayment. You have been asked to pay a $70 copayment for laboratory services. Laboratory services fall 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 forlaboratory services provided by "the provider" on August 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nebulizer provided to the enrollee on February 22, 2019 by out of network provider, "the provider".You asked the Plan to pay forthe nebulizer. You say that you received the purchase agreement from the ordering physician after the plan's deadline for authorization passed.The Plan denied your request. The Plan says that authorization was not granted.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 has network providers available who can provide 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 forthe nebulizer provided to the enrollee on February 22, 2019 by out of network provider, "the provider".
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay forthe comprehensive oral evaluation, prophylaxis, and bitewing x-rays provided on August 8, 2019.You asked the Plan to fully pay forthe comprehensive oral evaluation, prophylaxis, and bitewings. You say that you are allowed 1 exam, 1 cleaning,and 1 x-ray each year. You also say that you called and confirmed that this dental facility was in-network with your plan.The Plan denied your request. The Plan says these services were performed by a non-participating provider. The Plan also says thatthere is no record of a provider verification call from you prior to the services being rendered.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, your contract clearly states that there is a 50% coinsurance for comprehensive oral evaluation, prophylaxis, and bitewings. The record shows that yousaw an out-of-network provider, so the Plan does not have to fully pay for these services.Therefore, we decided that the Plan does not have to fully pay forthe comprehensive oral evaluation, prophylaxis, and bitewing x-rays provided on August 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided at the hospital from April 2, 2019 to April 11, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you feel that you should not be responsible for 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 $430 copayment per day for days 1-4 for inpatient hospital care. You had an inpatient hospital stay from April 2, 2019 to April 11, 2019. Therefore, you are responsible to pay a $430 copayment for days 1-4 (April 2, 2019 to April 5, 2019). The total amount you owe is: $430 (copayment) x 4 (inpatient days) = $1,720.00. You have been asked to pay the total copayment amount of $1,720.00 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 hospital stay provided at the hospital from April 2, 2019 to April 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on February 28, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not be liable for this. The Plan denied your request. The Plan says that 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 a $325 copayment for Ambulance services. You have been asked to pay a $325 copayment for the ambulance transport. The ambulance transport falls 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 the ambulance transport provided on February 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not haveto waive the copayments forthe laboratory services provided on May 21, 2019.You asked the Plan to waive the copayments forthe laboratory services. You say that you should not be responsible for the copayments because the lab services were rendered during your annual physical visit.The Plan denied your request. The Plan says you have been charged 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 $20 copayment for Medicare-covered laboratory tests. This copayment does not apply to blood draws or INR testing (anti-coagulant testing). You will only pay one copayment per day even if multiple lab tests are performed. You have been asked to pay a total of $30.79 for the laboratory services. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. See chart below.
Date of ServiceServiceAllowed AmountCopaymentMember LiabilityMay 21, 2019Hemoglobin test$10.79$20.00$10.79May 21, 2019Metabolic panel test$9.40$20.00$9.40May 21, 2019Lipid panel test$10.60$20.00$10.60Total$30.79This 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 forthe laboratory services provided on May 21, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided by the practice.
You asked the Plan to waive the copayment for the ambulance services. You say that you did not realize there would be a copayment. The Plan denied your request. The Plan says you were charged this cost sharing 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 $275 copayment for each ambulance date of service. You had one ambulance day of service. The Plan charged you $275 for these services. 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 ambulance services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency care services provided on April 3, 2018.You asked the Plan to pay for emergency care services. You say that the codes billed constitute a separate procedure from the previously paid surgical services, and are not a component of the same procedure.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 limits.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 emergency care services was not filed until August 8, 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 emergency care services provided on April 3, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from July 2, 2019 to July 9, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services provided from July 2, 2019 to July 9, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pay forphysical therapy services (CPT 97110 and HCPCS G0283) provided to the enrollee on May 23, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe records do not support the service billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services withthe appropriate CPT code.In this case, the CPT Code Manual definition of the denied codes is:CPT 97110:therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance,range of motion and flexibility.HCPCS G0283:Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules todetermine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found G0283 is not supported. The record does not contain evidencethat electrical stimulation was performed on the date of service in question. The record does not clearly support the units reported for 97110. It cannot be verified how much time was spent actually performing therapeutic exercises.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 services have not been met.Therefore, we decided that the Plandoes not haveto pay forphysical therapy services (CPT 97110 and HCPCS G0283) provided to the enrollee on May 23, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility (SNF) care provided from June 1, 2019 to June 8, 2019.
You asked the Plan to pay for SNF care. You say that these services were billed appropriately. The Plan denied your request. The Plan says that the units billed do not correlate to the date span.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care at issue have been met. Specifically, 8 units of SNF care were billed for 8 days of SNF care. The provider did not bill for services for which no Part A payment may be made (such as date of discharge June 9, 2019). Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) care provided from June 1, 2019 to June 8, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on February 15, 2017.
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says the claim was submitted after the filing date.
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 hearing aids was not filed until July 10, 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 reimburse you for hearing aids provided on February 15, 2017.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning services provided to the enrollee.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain 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 the denied codes is: CPT 99497: Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate CPT 99498: Advance care planning including the explanation and discussion of advance directives such as standard forms(with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure) We asked our coding 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found CPT codes 99497 and 99498 are not supported. The record does not contain evidence that advance care planning and the discussion of advance directives was performed for any length of time on this date of service. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for advance care planning services provided to the enrollee.