Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment charged for ambulance transport provided on August 20, 2020.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was applied based on your Medicaid eligibility and your Plan contract. Maximus overturned the Plans denial. The Plan requested a reopen and stated that your current Medicaid eligibility only applies to assistance with Part B Premiums. The Plan stated the contract explains there will be a $200 copayment for this service depending on Medicaid eligibility. The Plan confirmed that you are not fully qualified to receive help through Medicaid for Part A and/or Part B premiums and relief of copayments.
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 ambulance transport if you are not fully Medicaid eligible. The Plan has confirmed that you are not fully Medicaid eligible. 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 charged for ambulance transport provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to payforthe intraoral -periapical each additional radiographic image (D0230), and the periodontal scaling and root planing -one to three teeth per quadrant (D4342 x2) received March 10, 2021.You asked the Plan to pay forthe intraoral radiographic image and periodontal scaling and root planing. You say that the Plan should pay for the requested services.The Plan denied your request. The Plan says the requested services are either not covered under your supplemental benefit or exceed the frequency limitation for the service.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.Thoughthe Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit or are in excess of what is covered under this benefit. There is no coverage for periodontal scaling and root planing. The Plan limits coverage of intraoral radiographic images to one procedure per calendar year. The Plan has covered one procedure for intraoral radiographic images on this date of service. The second intraoral radiographic procedure is your responsibility. Therefore, we decided that the Plan does not have to pay forthe intraoral -periapical each additional radiographic image (D0230), and the periodontal scaling and root planing -one to three teeth per quadrant (D4342 x2) received March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic testing (D0431) provided on February 16, 2021.
You asked the Plan to pay for the pre-diagnostic testing. You say that you attended an informational meeting regarding the changes in your 2020 coverage. You say that you were advised there would be some coverage for services performed out of network. You say that there were no changes from 2020 to 2021. You also say that the services you received were not paid. The Plan denied your request. The Plan says pre-diagnostic testing is not listed as a covered service.
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 pre-diagnostic testing is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the adjunctive
pre-diagnostic testing (D0431) provided on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 2, 2021, by an OON
provider.
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan
denied your request. The Plan says no prior authorization was 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 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 office visit provided on April 2, 2021, by an
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three crowns (D2740 x3), core buildup, including any
pins when required (D2950), and prefabricated post and core in addition to crown (D2954) provided on January
5, 2021.

You asked the Plan to pay for the crowns, core buildup, and prefabricated post and core. You say that you have
a $2,000 reimbursement plan for the 2021 plan year. You also say that the Plan owes you $1,364, which is the
remaining balance. The Plan denied your request. The Plan says these services are not covered. The Plan also
says that the EOC clearly states under the dental plan summary, that coverage is limited to those services
described in the Summary of Benefits, and if a service is not listed, it 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 pay for the three
crowns (D2740 x3), core buildup, including any pins when required (D2950), and prefabricated post and core
in addition to crown (D2954) provided on January 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fourteen (14) additional PT visits.
You asked the Plan to pre-approve additional PT visits. You say that the additional PT visits are medically necessary. The Plan denied your request. The Plan says fourteen (14) additional PT visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 fourteen (14) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the medical records demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment for the enrollee in this case, however the documentation does not support that a total of fourteen (14) additional PT visits are medically reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of fourteen (14) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve fourteen (14) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99397, G0439) provided on February 19, 2021, by an out of network (OON) provider.

You asked the Plan to pay for an office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.

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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit (99397, G0439) provided on February 19, 2021, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an extraction (D7210), and a crown (D2740) provided from November 25, 2020, through December 2, 2020.
You asked the Plan to pay for an extraction, and a crown. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an extraction (D7210), and a crown (D2740) provided from November 25, 2020, through December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99211) and x-ray (72082) provided by a chiropractor on January 20, 2021.

You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary.The Plan denied your request. The Plan says these services were not spinal manipulation of the spine and are not covered when provided by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for an office visit (99211) and x-ray (72082) provided by a chiropractor on January 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by codes 97110 and 97140
provided on September 25, 2019.
You asked the Plan to pay for the therapy 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. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 97110 and 97140 are not supported in the medical record. Specifically, the records
indicate that the services were performed by a physical therapist assistant in a home health or hospice setting.
There are more appropriate codes for the billed services provided in a home health setting. Based on this
information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore,
we decided that the Plan does not have to pay for the therapy services represented by codes 97110 and 97140
provided on September 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0428)
received March 6, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you could not
utilize the Plan's door-to-door supplemental benefit from the hospital to the home. The Plan denied your
request. The Plan says the correct cost share applied to the claim.
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 Ambulance Services.
You have been asked to pay a $200 copayment for the ambulance transportation. The ambulance transportation
falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
the ambulance transportation (A0428) received March 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary and mandibular partial dentures - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213, D5214) received March 3, 2021.
You asked the Plan to pay for the maxillary and mandibular partial dentures. You say that the Plan should cover the maxillary and mandibular partial dentures. The Plan denied your request. The Plan says reimbursement was previously issued for maxillary and mandibular partial dentures on September 24, 2018.
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 covered under this benefit once every 5 years. The Plan has submitted evidence that maxillary and mandibular
dentures were covered on September 24, 2018. When you received the maxillary and mandibular dentures on March 3, 2021, your benefit for this procedure was exhausted. Therefore, we decided that the Plan does not have to pay for the maxillary and mandibular partial dentures - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213, D5214) received March 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a laryngoscopy provided on January 26, 2021.
You asked the Plan to waive the copayment for a laryngoscopy. You say that you received the service in a providers office and not in an outpatient hospital facility. 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 $300 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The record shows that you received a laryngoscopy on January 26, 2021, at an outpatient hospital facility. A laryngoscopy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $245.34, which is less than the $300 copayment.
You have been asked to pay a $300 copayment for a laryngoscopy. A laryngoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 laryngoscopy provided on January 26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram provided on January 10, 2021.

You asked the Plan to pay for the testing services. You say that this is a payable procedure code.The Plan denied your request. The Plan says the reports do not meet the requirements.

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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. We find that CPT code 93010 is not supported in the medical record. Specifically, the medical records provided do not include an interpretation and report from the provider. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay for the electrocardiogram provided on January 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for kidney stone removal provided a participating provider on June 3, 2020, to June 8, 2020.
You asked the Plan to waive the copayment for kidney stone removal. You say that this was just for kidney stone removal. You say that there was no surgery performed. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for outpatient surgery/outpatient surgery.
The enrollee has been asked to pay a $250 copayment for kidney stone removal. Kidney stone removal services are considered an outpatient surgery; therefore, the correct copayment has been applied. Kidney stone removal falls within the outpatient surgery/outpatient surgery 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 kidney stone removal provided a participating provider on June 3, 2020, to June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of a skin substitute graft (15275) rendered by
the OON provider on February 23, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.

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 had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the application of a skin substitute graft (15275) rendered by the OON provider on
February 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 that you were admitted for syncope after recent hospitalization for stroke. Medical conditions are stable. 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. Although you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for extracapsular cataract removal ambulatory surgery (66984, 65820) provided on January 19, 2020.
You asked the Plan to waive the coinsurance for cataract removal surgery. You say that you are not in agreement with the coinsurance applied. The Plan denied your request. The Plan says the coinsurance 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 a 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.
You have been asked to pay a 20% coinsurance for cataract removal surgery. The allowed amount of the claim is $2,574.17, resulting in a coinsurance obligation of $514.84. Cataract removal surgery falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for extracapsular cataract removal ambulatory surgery (66984, 65820) provided on January 19, 2020.