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

We decided that the Plan does not have to pay for the porcelain crown (D6740) or the porcelain bridge (D6245) provided by the Dental Provider on February 28, 2019.
You asked the Plan to pay for the crown (D6740) and the bridge (D6245). You say that you should be reimbursed for the amount you paid out-of-pocket since the claims were denied. You say you were told the replacement of your non-removable bridge would be covered. The Plan denied your request. The Plan says the 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 crown (D6740) and the bridge (D6245) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the porcelain crown (D6740) or the porcelain bridge (D6245) provided by the Dental Provider on February 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device (E0652) and compression stocking (A4495).
You asked the Plan to pay for intermittent limb compression device and compression stockings. You say that when you went to the pharmacy where the procedure was done, that they would be covered contrary to what the plan told you. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for preventative services. The compression stockings are also noncovered items.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Additionally, the compression stockings are not covered because they are wound care items and do not meet the definition of a dressing. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device (E0652) and compression stocking (A4495).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided out of network on March 1, 2019 by The physician .You asked the Plan to waive or reduce this cost share. You say that you do not believe you are responsible this bill.The Plan denied your request. The Plan says you were billed based on the contract agreement for out of network specialist services. 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 there is a 50% coinsurance for out of network specialist services. 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. 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 physician services provided out of network on March 1, 2019 by the physician.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided by "the provider" from August 13, 2019 to November 1, 2019.You asked the Plan to pay fortest strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided by "the provider" from August 13, 2019 to November 1, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 2, 2019.
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 Healthcare Common Procedural Coding System (HCPCS) G0483 remains not supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on July 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 8, 2019.You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the documentation submitted did not include a signed physician order or signed laboratory requisition.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 a valid physician order or lab requisition stating exactly which testing was to 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 July 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided at "the provider" from August 19, 2019 to August 20, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you feel that you were discharged too soon and 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 $425 copayment per admission for inpatient hospital care. You have been asked to pay a $425 copayment 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 foran inpatient hospital stay provided at "the provider" from August 19, 2019 to August 20, 2019.Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the crown (D2752) provided.You asked the Plan to pay more for the crown (D2752). You say that you are requesting reconsideration of the reminder of the payment. The Plan denied your request. The Plan says the maximum benefit limit has been reached.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 this a benefit limit of $1,000 every year for comprehensive dental services. The record shows that prior to the September 11, 2019 service Plan had paid $780.80 towards comprehensive dental services. ($1,000 -$780.80 = $219.20). Therefore, we decided that the Plan does not have to pay more for the crown (D2752) provided on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided out of network to the enrollee on August 22, 2019.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 the enrollee did not have prior authorization for out of network care.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 for the physician services provided out of network to the enrollee on August 22, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the clinical crown lengthening provided by on May 20, 2019.You asked the Plan to pay for the crown lengthening. You say that you pay a total of $275.The Plan denied your request. The Plan says this service is not covered in your 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.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 clinical crown lengthening provided on May 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee on May 13, 2019 by the physician.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 caseis 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 medical services provided to the enrollee on May 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on March 15, 2019.You asked the Plan to pay for hospital discharge day management. You say that this should be reprocessed.The Plan denied your request. The Plan says the submitted discharge summary does not support that this code was performed.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 99239 is hospital discharge day management; more than 30 minutes.We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted medical records do not contain documentation of the time spent on this service. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management have not been met.Therefore, we decided that the Plan does not have to pay for hospital discharge day management (99239) provided on March 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided by the doctor.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that when you arrived at your appointment you were informed you would have a copay responsibility for the x-rays and evaluation. The Plan denied your request. The Plan says there is no coverage for a complete series of x-rays according to your Evidence of 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan provides a list of covered services which shows that they will only cover bitewing x-rays. The Plan is not obligated to pay for the complete series of intraoral x-rays because it is not listed as a covered service. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays provided by the doctor.
Your complaint about the two dental providers taking advantage of the elderly population is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for computerized corneal topography provided on August 28, 2019.You asked the Plan to pay for the computerized corneal topography. You say that the medical records will support the medical necessity of computerized corneal topography that was done prior to cataract surgery on the right eye.The Plan denied your request. The Plan says experimental or investigational services are not covered.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 pay for the computerized corneal topography. Our reviewer says that computerized corneal topography is not medically reasonable and necessary.Our physician reviewer found that computerized corneal topography is primarily used for the evaluation of corneal diseases, disorders, abnormalities, or injuries. Covered diagnoses may include such diagnoses as astigmatism, keratoconus, and complications of a corneal graft. While it is documented in the Eye Institute's office visit note dated August 29, 2019 that this enrollee had corneal verticillata bilaterally, this condition did not require additional evaluation or treatment.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 computerized corneal topography have not been met.Therefore, we decided that the Plan does not have to pay for computerized corneal topography provided on August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have topay forthe chiropractic manipulations, 1 to 2 regions, and 2 therapeutic massage, each 15 minutes, provided from July 20, 2019 to July 27, 2019 by the out of network provider.You asked the Plan to pay forthe chiropractic care. You say that youcan no longer afford to continue your chiropractic care which has helped you immensely. You say that the Graston technique is not a common practice among chiropractors.The Plan denied your request. The Plan says authorization was not obtained before you received the services. The Plan says the services were not urgent or emergent. The Plan also says the services could be provided in 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 provider in this case is not a network provider with the Plan. The Plan has network providersavailable 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 nothave to pay forthe chiropractic manipulations, 1 to 2 regions, and 2 therapeutic massage, each 15 minutes, provided from July 20, 2019 to July 27, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Vitamin D testing (CPT 82652) provided on July 12, 2019.You asked the Plan to pay forthe Vitamin D testing. The Plan denied your request. The Plan says the services were not medically necessary.The Plan follows Medicare rules. Medicare rules say that Vitamin D testing is covered for the above indications.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 denyingthe request to pay for the Vitamin D testing. Our reviewer says that the Vitamin D testing was not medically reasonable and necessary. Our physician reviewer found that the enrollee reported fatigue and alterations of consciousness. The enrollee does not have any conditions for which the requested testing (CPT 82652) is indicated.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 Vitamin D testing have not beenmet.Therefore, we decided that the Plan does not have to pay forthe Vitamin D testing (CPT 82652) provided on July 12, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you fainted and fell to the floor. An ambulance was called and the responding paramedics evaluated you upon arrival. You say that your condition had normalized and you decided not to go to the hospital.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 June 19, 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 forthe ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on July 31, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says they were unable to make a determination within the allotted time frame.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 laboratory services provided on July 31, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided by on September 12, 2019.You asked the Plan to waive the copayment for the diagnostic mammogram. You say that this was supposed to be preventive. You say that this should be covered 100%. The Plan denied your request. The Plan says the claim reprocessed to apply a copayment.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 $10 copayment for each basic imaging service. You have been asked to pay a $10 copayment for the diagnostic mammogram. The diagnostic mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that you have a personal history of breast cancer. 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 diagnostic mammogram provided by on September 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an ophthalmological medical examination and evaluationprovided by on September 4, 2019.You asked the Plan to pay for the ophthalmological medical examination and evaluation. The Plan denied your request. The Plan says you have exhausted your benefit.Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers theseservices per calendar year.We looked at thefile and the Plan's rules. The file shows that you received an eye exam on August 7, 2019.Therefore, we decided that the Plan does not have to pay for an ophthalmological medical examination and evaluation provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 10, 2019 by out of network provider, "the doctor".You asked the Plan to pay fornursing home care. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for the service in question.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 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 medical services provided on June 10, 2019 by out of network provider, "the doctor".