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

 
We decided that the Plan does not have to pay for the panoramic x-ray provided on January 30, 2020. 
 
You asked the Plan to pay for the x-ray. You say that you told the hygienist your plan did not cover this x-ray. 
The Plan denied your request. The Plan says this is a non-covered service under your dental plan. 
 
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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the provided x-ray services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
panoramic x-ray provided on January 30, 2020.  
 
Your complaint about receive a service you told them your plan would not cover 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (76377) with 3D 
rendering (73700) provided on August 20, 2020. 
 
You asked the Plan to pay for a CT scan with 3D rendering. You say that the enrollee had multiple exams. The 
Plan denied your request. The Plan says this was previously billed and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that an additional unit of CPT code 76377 and 73700 is not supported in the medical record. The 
medical record only supports one unit each of CPT code 76377 and 73700, which was previously billed and 
paid. Based on this information, we decided that Medicare rules for coverage of a CT scan with 3D rendering 
have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) 
scan (76377) with 3D rendering (73700) provided on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a surgeon's office visit provided on August 
18, 2020. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you feel like the charge for 
this visit should only be $10. The Plan denied your request. The Plan says the copayment 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 $40 
copayment for each specialist visit.  
 
You have been asked to pay $40 copayment for specialist office visit. Specialist office 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 for a surgeon's office visit provided on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
26, 2020 to May 25, 2020. 
 
You asked the Plan to pay for home health services. The Plan denied your request. The Plan says the RAP 
claim was not billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
documentation does not show that a valid RAP form was submitted. Therefore, we decided that the Plan does 
not have to pay for the home health services provided to the enrollee from April 26, 2020 to May 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for hearing aids out-of-network. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria is not met and the provider is out of 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral for hearing aids out-of-network.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The 
Plan says care could be received in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable 
and necessary as described above. 
 
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 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 surgical repair of a hip fracture after a fall. 
Medical conditions are stable. There are no medical needs requiring inpatient admission. 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. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. 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 
admission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adding a tooth to an existing partial denture (D5650) 
provided on July 14, 2020. 
 
You asked the Plan to pay for adding a tooth to an existing partial denture. You say that the service should be 
covered. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. Any service not listed in the 
Plan?s 2020 EOC is not covered. 
 
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. Specifically, you received a service that is not listed in the Plan?s 2020 
EOC, and therefore, is not a covered benefit. Therefore, we decided that the Plan does not have to pay for 
adding a tooth to an existing partial denture (D5650) provided on July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on June 29, 2020, to July 20, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that these visits were in 
relation to your colonoscopy. You say that these should be covered. The Plan denied your request. The Plan 
says the correct copayments have 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 $50 
copayment for physician/practitioner services/in-network/specialist's office.  
 
You have been asked to pay a $50 copayment for a specialist office visit. The total amount you are being asked 
to pay is $100 ($50 x 2 visit = $100). Since two office visits were provided, the correct copayment has been 
applied. A specialist office visit falls within the physician/practitioner services/in-network/specialist's office 
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 a specialist office visit provided 
by a participating on June 29, 2020, to July 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 24, 2020.
You asked the Plan to pay for the ambulance services. You say that you became unconscious from being diabetic and the medics treated you in place. 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 April 24, 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 provided on April 24, 2020.
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 needed foot orthotics from your operation you received on your foot. 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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the eye exam (92015) provided on July 31, 2020.
You asked the Plan to pay for the eye exam. You say that the service should be covered. The Plan denied your request. The Plan says that eye refractions are only covered by your plan if performed by a participating provider and performed as a routine screening.
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 one annual routine eye exam, including eye refraction, to determine changes in your vision and/or the need for eyeglasses or contact lenses when provided by a  Provider, with a $0 copay. We looked at the file and the Plan's rules. You received the eye exam from a  Provider and the record does not show that you have previously exhausted your one supplemental routine eye exam for the 2020 calendar year. Based on this information, we decided that the Plan's rules for coverage of eye exam have been met. Therefore, we decided that the Plan has to pay for the eye exam (92015) provided on July 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames (V2020) and lenses (V2100) provided on December
12, 2019.
You asked the Plan to pay for the frames and lenses. You say that you would like reconsideration for the
remaining allowance because you had no other eyeglasses in 2019 other than the ones in dispute. The Plan
denied your request. The Plan says payment for this service has already been made to the 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 a $100 benefit maximum towards the purchase of 
eyeglass frames, standard eyeglass lenses, and contact lenses.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the frames and lenses have not been met. The record indicates that the Plan has paid the maximum
benefit allowance to the provider. You are responsible for the remaining balance. Therefore, we decided that
the Plan does not have to pay for frames (V2020) and lenses (V2100) provided on December 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic laryngoscopy (31575) and self-administered medication (A9270) provided on September 12, 2019.
You asked the Plan to waive the copayment for the diagnostic laryngoscopy and self-administered medication. You say that you should only be responsible for the $40 specialist copayment since you were not aware the procedure performed would be an additional cost. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $200 copayment for outpatient surgery. You have been asked to pay $164.89 for the diagnostic laryngoscopy and self-administered medication. $154.89 (the allowed amount for the diagnostic laryngoscopy) and $10 (for the self-administered medication) equals $164.89. A diagnostic laryngoscopy falls within the outpatient surgery 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 a diagnostic laryngoscopy (31575) and self-administered medication (A9270) provided on September 12, 2019.
Benefits for the self-administered medication 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 12, 2020.
You asked the Plan to pay for the ambulance services. 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 April 12, 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 provided on April 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided March 10, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. 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 March 10, 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 provided on March 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on June 5, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you thought these service
would have been covered under your specialist copayment. 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 $450
copayment for outpatient surgery.
You have been asked to pay a $450 copayment for an outpatient surgery. an outpatient surgery falls within the
outpatient surgery 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 outpatient surgery
provided on June 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a DEXA scan (CPT 77080) provided to the enrollee on
January 27, 2020.
You asked the Plan to pay for the scan. You say that this sohuld be paid for. The Plan denied your request. The
Plan says there is no additional documentation supporting an additional study which was billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 77080 is "Dual-energy X-ray absorptiometry (DXA),
bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)."
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 scan. Our reviewer says that the services
at issue in this case were not supported by the medical records. Our physician reviewer found a review of the
submitted materials show a single DEXA scan was done on the enrollee and dated 1/27/20. The problem here is
that there are no records submitted to justify the exam and no written order is found. Absent
such documentation even though the formal dictation lists as a history a valid indication reimbursement can't be
approved absent chart notes and a written order by the referring physician.
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 scan have not been met. Therefore, we decided that the Plan does not have
to pay for a DEXA scan (CPT 77080) provided to the enrollee on January 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided by a 
participating provider on February 3, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that this should be covered 
100%. 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 $45 
copayment for outpatient diagnostic tests/x-ray.  
 
You have been asked to pay a $45 copayment for a diagnostic ultrasound. Since the test was diagnostic in 
nature, the correct copayment has been applied. A diagnostic ultrasound falls within the outpatient diagnostic 
tests/x-ray 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 a diagnostic ultrasound 
provided by a participating provider on February 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
November 6, 2020, through November 9, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should have to pay the 
cost share. The Plan denied your request. The Plan says the cost share 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 $310 
copayment per day for days one through six for inpatient hospital care.  
 
You have been asked to pay a $310 copayment for inpatient hospital care for three days. This service 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 
inpatient hospital care provided on November 6, 2020, through November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard. 
 
You asked the Plan to pre-approve these services. You say that you need the device to stop grinding your teeth. 
The Plan denied your request. The Plan says the services 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 pre-approve an 
occlusal guard.