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

We decided that the Plan does not have to reduce the copayment for a medical eye examination (92014) provided on March 9, 2021.

You asked the Plan to reduce the copayment for a medical eye examination. You say that you went for a routine eye examination. The Plan denied your request. The Plan says if you receive services that address a medical condition during a routine office visit, you pay a $40 specialist office visit 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 $40 copayment for a medical eye examination. 

You have been asked to pay a $40 copayment for a medical eye examination. The service at issue falls within the vision 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 reduce the copayment for a medical eye examination (92014) provided on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to hold you harmless for the wrist-hand-finger orthosis provided on March 15, 2021.
You asked the Plan to hold you harmless for the orthosis. You say that this is being denied since it is durable medical equipment. You do not believe this is correct since it was a cast for your thumb. The Plan denied your request. The Plan says that this item was billed with an office place of service (POS) code. The POS code is not valid since the location the item will be used should be reported.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were provided with the orthosis by a contract provider. The file does not show that the Plan provided notice that the orthosis would not be covered. This is a billing issue that must be resolved between the Plan and the contract provider. Under Medicare rules, this means the orthosis is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the wrist-hand-finger orthosis provided on March 15, 2021.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 29, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the services provided by an out-of-network provider on October 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on November 9, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid face-to-face evaluation.

The Plan must follow Medicare rules. The rules say that an in-person, face-to-face interaction between the beneficiary and their treating physician is required prior to prescribing durable medical equipment. 

We looked at the file and Medicare rules. There is no valid face-to-face evaluation with a physician for the durable medical equipment. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on November 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 5, 2020.
You asked the Plan to pay for the ambulance services. You say that you fell, and the medics assisted you back up. 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 December 5, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retreatment of previous root canal therapy (D3348) to be rendered by an OON provider.

You asked the Plan to pre-approve the retreatment of previous root canal therapy. You say that you need this taken care of because your regular dentist found an infection, and you cannot eat. You also say that the Plan advised the closest dental provider is located 4 or 5 hours from you. The Plan denied your request. The Plan says services by an OON provider are not covered. The Plan also says that there are available in-network providers.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a retreatment of previous root canal therapy (D3348) to be rendered by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on January 18, 2021.
You asked the Plan to waive the copayment for lab work. You say that this was part of your annual wellness exam. You say that you should not have to pay for this. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for outpatient diagnostic tests/laboratory tests. You have been asked to pay a $10 copayment for lab work. When additional services are provided during an annual wellness exam, additional copayments can be applied; therefore, the correct copayment has been
applied. Lab work falls within the outpatient diagnostic tests/laboratory tests 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 lab work provided by a participating provider on January 18, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an abutment supported crown (D6058), and a custom fabricated abutment (D6057) provided on February 16, 2021.

You asked the Plan to pay for an abutment supported crown, and a custom fabricated abutment. You say that the services at issue should be covered. 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 abutment supported crown (D6058), and a custom fabricated abutment (D6057) provided on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extra-oral posterior dental x-ray (D0251), preventive procedure (D1999), problem focused limited oral evaluation (D0140), and panoramic x-ray (D0330) provided on March 1, 2021 by an OON provider.

You asked the Plan to pay for the extra-oral posterior dental x-ray, preventive procedure, problem focused limited oral evaluation, and panoramic x-ray. You say that you were not aware that the treating provider was OON. The Plan denied your request. The Plan says the extra-oral posterior dental x-ray and preventive procedure are not covered services. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the covered services.

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, extra-oral posterior dental x-ray (D0251) and unspecified preventive procedure (D1999) are not among those covered under this benefit. Non-network dentists have not agreed to provide services at contracted fees. If you see an OON dentist, the coinsurance level will apply to the average negotiated in-network fee schedule (INFS) in your area. You are responsible for the difference between the INFS and dentists' charged fees when visiting an OON dentist. Therefore, we decided that the Plan does not have to pay for the extra-oral posterior dental x-ray (D0251), preventive procedure (D1999), problem focused limited oral evaluation (D0140), and panoramic x-ray (D0330) provided on March 1, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for medical eye exam (99204) provided on March 19, 2021.
You asked the Plan to pay for medical eye exam. You say that you feel that you were not given the care you
needed and do not feel you should pay. The Plan denied your request. The Plan says the cost share has
processed 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 $40
copayment for Medicare-covered eye exam.
You have been asked to pay a $40 copayment for medical eye exam. This service falls within the Medicarecovered
eye exam 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 pay for medical eye exam (99204) provided
on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye surgery and related services provided by an out-of-network provider on March 8, 2021.

You asked the Plan to pay for the eye surgery and related services. You say that you included the medical records for a medical necessity review. You say that the claim should be reprocessed for payment sine the service was medically necessary. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not 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 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 the eye surgery and related services provided by an out-of-network provider on March 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on December 15, 2020.

You asked the Plan to waive the copayment for specialist services. You say that you should not have a copayment for this. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for physician/practitioner services/specialist. 

You have been asked to pay a $30 copayment for specialist services. The correct copayment has been applied to the services that were provided. Specialist services fall within the physician/practitioner services/specialist 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 specialist services provided by a participating provider on December 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the positron-emission tomography (PET)
imaging provided on March 1, 2021, billed with diagnosis code C18.9.
You asked the Plan to pay for the PET interpretation as billed. You say that the records support that this service
was medically necessary. The Plan denied your request. The Plan says this was not billed with an appropriate
diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are
based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis
codes that may be used.
We looked at the file and Medicare rules. We found that diagnosis code C18.9 is not among the approved
diagnosis codes for this imaging. Based on this information, we decided that Medicare rules for coverage of the
PET interpretation as billed have not been met. Therefore, we decided that the Plan does not have to pay for the
interpretation of the positron-emission tomography (PET) imaging provided on March 1, 2021, billed with
diagnosis code C18.9.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 15, 2020 by an out of network (OON) provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were 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 requested provider in this case is not a network provider with the Plan. The referring provider 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 the laboratory services provided on September 15, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services provided on April 1, 2021 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating 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 referring provider 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 the debridement services provided on April 1, 2021 by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth office visit (99212) provided on February 5, 2021, by an out of network (OON) provider.

You asked the Plan to pay for an office visit. You say that the visit should be covered because you do not remember going to this provider's office on the date of service. 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 records provided by the provider confirm you had a telehealth visit with the provider. 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 a telehealth office visit (99212) provided on February 5, 2021, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the root canal (D3320) provided on February 25, 2021 by the out of network provider.
You asked the Plan to pay the full amount for the dental services. You say that you did not think that you would have to pay this amount. You also say that you would not have had this procedure at this time if you had known. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan says that the provider in this case is out of network. The Plan also says that out of network dentists may bill you for any amount greater than what the plan pays.
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 and limited oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on January 20, 2021. Additionally, out of network dentists may bill you for any amount greater than what the plan pays.
amount greater than what the plan pays.
CPT Code
Billed Amount
Allowed Amount
Difference
Plan Paid
Your Responsibility
D0140
$130
$0
$130
$0
$130
D0220
$50
$10
$40
$10
$40
D3320
$1,150
$362
$788
$362
$778
TOTAL:
$948
Therefore, we decided that the Plan does not have to pay the full amount for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the root canal (D3320) provided on February 25, 2021 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 8, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claims were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on March 26, 2021, to April 2, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were prematurely discharged. You say that you should not have to pay for this. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care/in-network.

You have been asked to pay a $300 copayment per day for days 1-6 for an inpatient hospital stay. The total amount you are being asked to pay is $1,800 ($300 x 6 days = $1,800). Since an inpatient stay was provided, the correct copayment has been applied. An inpatient hospital stay falls within the inpatient hospital care/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on March 26, 2021, to April 2, 2021.