Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care provided on August 29, 2019.

You asked the Plan to pay for the hospital care. You say that you did not receive proper notice of the enrollee's benefit determination. The Plan denied your request. The Plan says the claim was untimely.

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 hospital care was not filed until October 6, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for hospital care provided on August 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953).

You asked the Plan to pay for the bone replacement graft. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not a covered benefit 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.

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 bone replacement graft for ridge preservation (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits provided from August 18, 2020, to August 25, 2020.
You asked the Plan to waive the copayments for office visits. You say that these were follow-up visits to a surgery and 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 $10 copayment for physician/practitioner services, including doctor's office visits. You had follow-up visits from August 18, 2020, to August 25, 2020, for a total of 3 visits. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay a $10 copayment per each visit. The total amount you owe is: $30. You have been asked to pay the total copayment amount of $30 for office visits. Office visits fall 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 copayments for office visits provided from August 18, 2020, to August 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from July 17, 2020, to July 24, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the enrollee cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $275 copayment for days 1-5 for inpatient hospital care. 

The enrollee had an inpatient hospital stay form July 17, 2020, to July 24, 2020. Therefore, the enrollee is responsible to pay a $275 copayment for days 1-5 (July 17, 2020, to July 21, 2020). $275 (copayment) x 5 (inpatient days) = $1,375. 

The enrollee has been asked to pay the total copayment amount of $1,375 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay from July 17, 2020, to July 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the treatment of lumbar spinal stenosis. The Plan denied your request. The Plan says this service is not medically necessary.

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 pre-approve this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the spacer device is experimental. More research is needed to show safety and efficacy of the device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit.

You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you were not aware that you would owe a copayment for telehealth services. 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 $40 copayment for each specialist visit.

You have been asked to pay a $40 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 for a specialist visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3310) for tooth #8.
You asked the Plan to pre-approve the endodontic therapy. You say that you would like this service approved so that the enrollee can continue with treatment. The Plan denied your request. The Plan says this service is 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 endodontic therapy (D3310) for tooth #8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full cost for an eye exam for prescription eye wear (refraction) (92015).

You asked the Plan to pay the full cost for a refraction. You say that you cannot afford this charge. The Plan denied your request. The Plan says this processed correctly.

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 with a $35 copayment.

We looked at the file and the Plan's rules. You have been asked to pay a $35 copayment for a refraction. This means that this service processed correctly according to the Plan's supplemental vision benefit. Therefore, we decided that the Plan does not have to pay the full cost for an eye exam for prescription eye wear (refraction) (92015).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services.

You asked the Plan to waive the copayment for podiatry services. You say that you were hoping that the services would be included in the copayment waiver. 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 $40 copayment for podiatry services.

You have been asked to pay a $40 copayment for podiatry services. Podiatry services fall within the podiatry 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 podiatry services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.
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 pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device is experimental. More research is needed to show safety and efficacy of the device. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six additions of tooth to an existing partial denture (D5650 x6), add clasp to existing partial denture (D5660), reline of a maxillary partial denture (D5740), and reline of a mandibular partial denture (D5741).

You asked the Plan to pre-approve the tooth additions to an existing partial denture, add clasp to existing partial denture, reline of a maxillary partial denture, and reline of a mandibular partial denture. You say that the enrollee was unable to obtain these services in 2020. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit package.

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 six additions of tooth to an existing partial denture (D5650 x6), add clasp to existing partial denture (D5660), reline of a maxillary partial denture (D5740), and reline of a mandibular partial denture (D5741).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the chest x-ray (71045) provided on May 25, 2020.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this service was denied as a duplicate in error. The Plan denied your request. The Plan says that CPT code 71045 is a column II code to column I code 71045 which was billed on the same date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 71045 is supported in the record. Specifically, the record indicates that the column I and column II codes were rendered by separate providers. NCCI edits do not apply to services rendered by separate providers. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have been met. Therefore, we decided that the Plan has to pay for the chest x-ray (71045) provided on May 25, 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ultrasounds provided on September 14, 2020.

You asked the Plan to waive the copayments for ultrasounds. You say that you disagree with the increase in 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 $110 copayment for each radiological diagnostic service. 

You received two ultrasounds on September 14, 2020. Therefore, you are responsible to pay a $110 copayment per each ultrasound. The total amount you owe is: $220. 

You have been asked to pay the total copayment amount of $220 for ultrasounds. Ultrasounds 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 copayments for ultrasounds provided on September 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 74230.

You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 74230 is radiologic examination, swallowing function, with cineradiography/videoradiography, including scout neck radiograph(s) and delayed image(s), when performed, contrast (eg, barium) study.

We find that CPT code 74230 is not supported in the medical record. Specifically, this service was billed with place of service 22 (outpatient); however, the documentation supports that the enrollee was inpatient during this date of service. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 74230.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services (99282) provided on August 13, 2020.

You asked the Plan to pay for the emergency room services. You say that you would like reconsideration because recovery for services provided to eligible beneficiaries is not extinguished by specific plan requirements. The Plan denied your request. The Plan says the claim was not billed in accordance with the Centers for Medicare & Medicaid Services guidelines.

The Plan must follow Medicare rules. Medicare rules say that all charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue code 0510. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Specifically, this service has not been billed with the appropriate revenue code. Therefore, we decided that the Plan does not have to pay for the emergency room services (99282) provided on August 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 20, 2020, to April 21, 2020.

You asked the Plan to pay for SNF care. You say that you have a single case agreement for these services. The Plan denied your request. The Plan says these services were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that SNFs and hospital swing bed providers are required to report inpatient Part A PPS billing data with Revenue Code 0022. 

We looked at the file and Medicare rules. The services at issue were not reported with Revenue Code 0022. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 20, 2020, to April 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the bone graft for ridge preservation (D7953), the scaling and root planing (D4341 x 2), and the application of fluoride (D1208).

You asked the Plan to pay more for the dental services. You say that you do not agree with the member responsibility on this claim. You say that you got services done that you did not ask for. You also say that you would like the claim to be reprocessed and paid. The Plan denied your request. The Plan says this claim was originally processed under your medical benefit. The Plan says bone graft for ridge preservation is not listed as a covered service. The Plan also says that the fluoride, and scaling and root planing were paid according to the 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 bone replacement graft for ridge preservation is not among those covered under this benefit. The Evidence of Coverage clearly shows that you pay 70% for the scaling and root planing. Additionally, the record shows that you signed a treatment plan acknowledging that you agreed to the services and to be financially responsible for the charges from the complete treatment. Therefore, we decided that the Plan does not have to pay more for the bone graft for ridge preservation (D7953), the scaling and root planing (D4341 x 2), and the application of fluoride (D1208).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a bone graft in conjunction with periradicular surgery (D3428), up to the maximum yearly allowance of $1,000 for comprehensive dental services.

You asked the Plan to pre-approve the bone graft in conjunction with periradicular surgery. You say that the services should be covered because you have been advised that you need the procedure, or it will deteriorate your jawbone. You say that you could suffer harm if the services are not rendered quickly, and that you are in a lot of pain. The Plan denied your request. The Plan says that the services in dispute are excluded from Medicare 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. Medicare rules say that plans must provide enrollees with a clear and accurate description of supplemental benefits offered under the plan contract, including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. 

We looked at the file and Medicare rules. The Plan has only explained their denial based on Medicare rules for non-coverage of the requested service. However, the enrollee's contract reads that there is coverage for dental services beyond Medicare's coverage. The Explanation of Benefits (EOB) states that the enrollee has a $1,000 yearly allowance for supplemental preventive and comprehensive dental services every year. The EOB does not provide the enrollee with a clear description of the limitations to this supplemental benefit. The Plan did not show that they accurately described the conditions associated with use or receipt of this benefit allowance. This means that the Plan did not follow Medicare rules for disclosure of supplemental benefit information, and that their contract is considered ambiguous. Therefore, we decided that the Plan has to pre-approve a bone graft in conjunction with periradicular surgery (D3428), up to the maximum yearly allowance of $1,000 for comprehensive dental services.