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

We decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350) provided December 8, 2020, and the resin-based composites (D2335, D2331) and unspecified preventive procedure, by report (D1999) provided December 11, 2020.
You asked the Plan to pay for the resin-based composites, unspecified dental procedure and 2D x-rays. You say that you were told your dental services would be covered. The Plan denied your request. The Plan says a 50% coinsurance was correctly applied to the resin-based composites and the 2D x-rays and unspecified preventative procedures aren't 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. The Plan covers the resin-based composites with a 50% coinsurance. Unspecified dental procedures and 2D x-rays are not on the Plan's list of covered benefits. We looked at the file and Medicare rules. You have been asked to pay 50% coinsurance for the resin-based composites. Based on this information, we decided that the Plan does not have to provide additional payment for the resin-based composites (D2335, D2331) provided December 8, 2020.
Though the Plan offers a dental benefit in excess of Medicare coverage, the 2D x-rays and unspecified preventative procedure are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350) provided December 8, 2020, and the unspecified preventive procedure, by report (D1999) provided December 11, 2020. Your complaint about potentially receiving misinformation from a plan representative 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS emergency ambulance (A0429) and ground mileage (A0425) provided August 12, 2020.
You asked the Plan to pay for the ambulance. You say that see attached as the enrollee required EMS transport. The Plan denied your request. The Plan says the claim history indicates the enrollee was in inpatient hospital status.
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 records show that the enrollee was in an inpatient hospital status from August 10, 2020 to August 16, 2020. Therefore, ambulance services used for the transportation of a hospital inpatient to another facility is considered part of the inpatient admission and not separately payable. Based on this information, we decided that Medicare rules for coverage of the ambulance have not been met. Therefore, we decided that the Plan does not have to pay for the BLS emergency ambulance (A0429) and ground mileage (A0425) provided August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal protective equipment (D1999) provided on January 2, 2021.

You asked the Plan to pay for the dental service. You say that you should not be responsible for equipment due to the pandemic. You also say that you did not have to pay this fee. The Plan denied your request. The Plan says the personal protective equipment is not listed as a covered service and therefore is not reimbursable.

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 personal protective equipment (D1999) provided on January 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99223) provided on October 5, 2020.

You asked the Plan to pay for hospital care. You say that the enrollee was seen twice on this date of service. The Plan denied your request. The Plan says this is not separately payable without a modifier.

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, we have confirmed that code 99223 has a bundled relationship with code 49000 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99223) provided on October 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoride treatment (D1206).

You asked the Plan to pay for the fluoride treatment. You say that you need the fluoride treatment because your water is sourced from a well. The Plan denied your request. The Plan says fluoride treatments are excluded from 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 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 fluoride treatment (D1206).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the outpatient office visit (99213) provided October 28, 2020.

You asked the Plan to pay for the office visit. You say that you received bills from both facilities, and you have never had to pay before. The Plan denied your request. The Plan says that this claim was processed correctly to the deductible. The enrollee only reached $198.00 from his maximum out of pocket of $6,700.00.

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 enrollees must pay $0 copayment specialist's office for Physician/Practitioner services, including doctor's office visits.

The Plan says you must pay $76.54 towards the deductible for the office visit. Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment specialist's office. Per the plan's Evidence of Coverage there is no deductible. You are not responsible for paying any out-of-pocket costs toward the maximum out-of-pocket amount for covered Part A and Part B services. There is a limit to how much you have to pay out-of-pocket each year for medical services that are covered under Medicare Part A and Part B. This limit is called the maximum out-of-pocket amount for medical services. The most you will have to pay out-of-pocket for Part A and Part B services in 2020 is $6,700. Therefore, we decided that the Plan has to pay for the outpatient office visit (99213) provided October 28, 2020.

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 pay for the teeth extractions (D7140) and the maxillary and mandibular partial dentures (D5213, D5214) received November 10, 2020.

You asked the Plan to pay for the teeth extractions and partial dentures. You say that the requested items/services were necessary. The Plan denied your request. The Plan says the requested items/services are not covered under your supplemental 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. 

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 teeth extractions (D7140) and the maxillary and mandibular partial dentures (D5213, D5214) received November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames (V2020), Sphere, single vision (V2100) and polycarbonate lens (V2784) provided November 4, 2020.

You asked the Plan to pay for the frames and sphere, single vision polycarbonate lenses. You say that the frames should be covered on an annual basis. The Plan denied your request. The Plan says you did not receive the eyewear from a network optical provider and therefore it is not covered.

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 they are provided at a network optical provider.

We looked at the file and the Plan's rules. In this case you purchased frames and lenses from an out-of-network provider. The Plan only covers eyewear under your supplemental vision benefit when it is purchased from a network optical provider. Based on this information, we decided that the Plan's rules for coverage of the frames and sphere, single vision polycarbonate lenses have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020), Sphere, single vision (V2100) and polycarbonate lens (V2784) provided November 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Esophagogastroduodenoscopy provided on August 13, 2020.

You asked the Plan to waive the copayment for the Esophagogastroduodenoscopy (43239). You say that you cannot afford the copayment for the colonoscopy. The Plan denied your request. The Plan says you were charged this copayment 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 $295 copayment for Outpatient surgery at an outpatient hospital.

You have been asked to pay a $295 copayment for Esophagogastroduodenoscopy (43239). The Plan only assessed the copayment on the upper endoscopy services. Esophagogastroduodenoscopy (43239) falls within the Outpatient Surgery at an outpatient hospital 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 Esophagogastroduodenoscopy provided on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and panoramic x-ray provided on December 9, 2020.

You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that you cannot afford to pay this bill. The Plan denied your request. The Plan says benefits for these services have been satisfied and the frequency limitations have been exceeded.

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, comprehensive oral evaluation is limited to one procedure every three years, and full mouth or panoramic x-rays are limited to one procedure every five years. The record shows that you received a comprehensive oral evaluation and panoramic x-ray on February 26, 2020 and your comprehensive oral evaluation and panoramic x-ray benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and panoramic x-ray provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 14, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 had network providers available who could have provided 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 physician services provided on September 14, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine venipuncture (blood draw) provided on June 5, 2020 by an out of network (OON) provider.

You asked the Plan to pay for venipuncture. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 had network providers available who could have provided 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 a routine venipuncture (blood draw) provided on June 5, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hospital observation service, per hour (G0378) echocardiography, Transthoracic (93306) Radiologic examination, chest (71045) intravenous infusion, for therapy, prophylaxis, or diagnosis (96366) provided August 30, 2020.

You asked the Plan to waive the copayment for the hospital observation services. You say that your PCP office was closed for a mount and you were in a lot of pain and wanted to have your heart checked. You feel this should be waived because this was an emergency. The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per the Evidence of Coverage

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 $250 copayment for each covered outpatient hospital facility visit, clinic, outpatient treatment room, observation room, or outpatient surgery services.

You have been asked to pay $250 copayment for the hospital observation services. The hospital observation services fall within the Outpatient Hospital Observation 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 hospital observation service, per hour (G0378) echocardiography, Transthoracic (93306) Radiologic examination, chest (71045) intravenous infusion, for therapy, prophylaxis, or diagnosis (96366) provided August 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99281) provided on October 26, 2020.

You asked the Plan to pay for an emergency department visit. You say that this was billed correctly. The Plan denied your request. The Plan says the diagnosis indicates this was a screening service.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The service at issue in this appeal, an emergency department visit, was performed solely for screening purposes. It was billed with diagnosis Z13.9, encounter for screening, unspecified, and the medical records state that the visit was for a medical screening. Medicare does not cover this service solely for screening purposes. Therefore, we decided that the Plan does not have to pay for an emergency department visit (99281) provided on October 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397)
provided October 13, 2020.

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the requested items were
medically necessary. The Plan denied your request. The Plan says the patient did not receive a video or
telephonic visit by the ordering physician in order to warrant the codes billed.

The Plan must follow Medicare rules. Medicare rules say that a durable medical equipment supplier may not
contact an enrollee without first receiving permission.

We looked at the file and Medicare rules. In this case, the Plan has attested that the enrollee was contacted via
an unsolicited phone call regarding the provision of the items at issue. Based on this information, we decided
that Medicare rules for coverage of the knee orthosis and suspension sleeve have not been met. Therefore, we
decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397)
provided October 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from March 10, 2020 to April 9, 2020.

You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 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, home health services under a plan of care are paid based on a 60-day episode of care or a 30-day period of care. Payment for this episode or period will usually be made in two parts. After a RAP has been paid and an episode or period has been completed, or the patient has been discharged, the HHA submits a claim to receive the balance of payment due. In this case, the claim for dates of service March 10, 2020 to April 9, 2020 is a 31-day episode of care including "from" date. As the date of service billed is after January 1, 2020, a 30-day period of care is eligible, but the provider has billed a 60-day period of care. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from March 10, 2020 to April 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the laboratory services provided on February
1, 2020.

You asked the Plan to waive the cost share for the laboratory services. You say that you feel you should not be
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied
your request. The Plan says you received laboratory services on the date of service at issue in this appeal. The
Plan says that the correct amount has applied towards your deductible per your contract with the Plan. The Plan
says that you meant your deductible with the services provided on February 1, 2020, and your copayment also
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 there is $250 deductible that must be met before the Plan will pay their share
for Outpatient diagnostic tests. Your contract with the Plan also says there is a $30 copayment for Medicare-covered
lab services once the deductible has been met.

The item or service you asked the Plan to waive the cost share for falls within the benefit category Outpatient
diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $250
deductible that must be met before the Plan will pay their share for Outpatient diagnostic tests. This cost
sharing is a contractual obligation that had not been met until the laboratory services were received on February
1, 2020. As you have now met your deductible, you are also responsible for the $25 copayment applied, which
is less than the contracted $30 copayment amount. Therefore, we decided that the Plan does not have to waive
the cost share for the laboratory services provided on February 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology provided on December 24, 2020.

You asked the Plan to pay for the molecular pathology. The Plan denied your request. The Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 molecular pathology provided on December 24, 2020.