Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided October 6,
2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that this item was medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says the enrollee did not receive a video or
telephonic visit by the ordering physician in order to warrant the code billed.
The Plan follows Medicare rules. Medicare rules say that a knee orthosis and suspension sleeve are subject to
the criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer
says that the requested item was not medically reasonable and necessary. Our physician reviewer found an
appropriate history and a physical examination of the back would reasonably be required to adequately assess
whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support
that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is
insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a
credible physical examination of the back.
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 lumbar-sacral orthosis have not been met. Therefore, we decided that the
Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided October 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on November 20, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says 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 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 to the enrollee by an out-of-network provider on November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) and the panoramic x-ray (D0330)
provided on January 14, 2021.
You asked the Plan to pay for the dental service. You say that your dentist already had all of the information
needed to supply you with dentures. You say that you were about to get the molds done and an office person
came in saying the plan was requesting a panoramic x-ray. You say that the plan should pay the provider since
they requested the service. You also say that this dentist is excellent and should be paid for the services. The
Plan denied your request. The Plan says consultation is not listed as a covered service. The Plan also says that
the provider confirmed that you are not being billed for the panoramic x-ray.
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 consultation is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation
(D9310) and the panoramic x-ray (D0330) provided on January 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on September 9, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that the hospital could not do cardiac testing so you were transported to another hospital and you do not feel you should have to pay the copayment. The Plan denied your request. The Plan says you were charged this cost sharing 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 $150 copayment for each day of ambulance service. You had one ambulance trip/one day of service. The Plan charged you $150 for these services. 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 services provided on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on July 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 to the enrollee by an out-of-network provider on July 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the echocardiogram and the heart rhythm analysis provided on October 20, 2020.
You asked the Plan to reduce the cost share for the echocardiogram and the heart rhythm analysis. You say that the echocardiogram is a non-radiological service and should not be subject to the deductible or the $145 copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 a $1000 deductible that applies towards the in-network echocardiogram, a $145 copayment for each in-network Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic), and a $30 copayment in-network Medicare-covered non-radiological diagnostic services.
The echocardiogram and heart rhythm analysis you asked the Plan to reduce the cost share for falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible that applies towards echocardiograms, a $145 copayment for each in-network Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic) and a $30 copayment for in-network Medicare-covered non-radiological diagnostic services.
This cost sharing is a contractual obligation that had not been met at the time the echocardiogram and the heart rhythm analysis were received on October 20, 2020. Therefore, we decided that the Plan does not have to reduce the cost share for the echocardiogram and the heart rhythm analysis provided on October 20, 2020.
Your complaint that you were misled by the Plan 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nuclear medicine test (thyroid scan).
You asked the Plan to pre-approve the scan. You say that this is medically necessary to check the thyroid. The
Plan denied your request. The Plan says this is not part of a standard workup for your condition.
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 scan. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this scan will be of little use to you, as you are hyperthyroid. If you are in the recovery phase of
thyroiditis, the uptake may be high. If you are not, it may be lower. However, in either case the decision to treat
is based on your symptoms, and the scan/uptake will be of little help and is not indicated.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve a nuclear medicine test (thyroid scan).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on December 18, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says 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 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 to the enrollee by an out-of-network provider on December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance, physician, home care, and skilled nursing services provided January 27, 2020 to October 9, 2020.
You asked the Plan to pay for the medical services. You say that the out-of-pocket maximum was met at the time services were provided and the copayments should be refunded. The Plan denied your request. The Plan says the member's out-of-pocket maximum was not satisfied at the time services were provided, and the correct cost-sharing was applied to these claims.
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 combined out-of-pocket maximum of $10,000. At the time services were rendered, the total out-of-pocket amount the enrollee was responsible for (including copayments, deductibles, etc.) was $1708.00. This does not satisfy the $10,000 out-of-pocket maximum. 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 ambulance, physician, home care, and skilled nursing services provided January 27, 2020 to October 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for placement of intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922) and local anesthesia (D9215) provided on November 13, 2020.

You asked the Plan to pay for placement of intra-socket biological dressing to aid in hemostasis or clot stabilization and local anesthesia. You say that these services were medically necessary. The Plan denied your request. The Plan says these services are not a covered 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 placement of intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922) and local anesthesia (D9215) provided on November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic examination of ear and nose (92504) outpatient office visit (99213) removal impacted cerumen (69210) provided November 2, 2020 to November 13, 2020.
You asked the Plan to waive the copayment for the diagnostic and surgical services. You say that you believe the plan should have paid more on the claims and is appealing the processing of the claims. The Plan denied your request. The Plan says the claim was processed, and the correct cost share was applied per the Evidence of Coverage. The provider was out of network on November 13, 2020.
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 $45 copayment for covered hearing services, in network specialist's office visits and 50% coinsurance for surgery services at an out of network specialists office.
You have been asked to pay $151.01 ($45 + $61.01 + $45) for the diagnostic and surgical services. The diagnostic and surgical services fall within the Hearing services and 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 diagnostic examination of ear and nose (92504) outpatient office visit (99213) removal impacted cerumen (69210) provided November 2, 2020 to November 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 28, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item provided was medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the enrollee did not receive video or telephonic visit by ordering physician in order to warrant the codes billed.
The Plan follows Medicare rules. Medicare rules say that the spinal orthosis is subject to the criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the requested orthosis was not medically necessary and reasonable. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back. 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided on August 16, 2020, and August 17, 2020.
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was stable for transfer.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient care. Our reviewer says that the requested inpatient care is not medically reasonable and necessary. Our physician reviewer found that after 2:32 pm on August 16, 2020, to 10:18 pm on August 17, 2020, the enrollee was hemodynamically stable for ambulance transport with monitoring to a Plan facility. The post-stabilization care services were not medically necessary or reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. 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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided on August 16, 2020, and August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and intraoral periapical radiographic images (D0220) provided on November 11, 2020.
You asked the Plan to pay for a periodic oral evaluation and intraoral periapical radiographic images. You say that you were not aware of changes made to your dental coverage. The Plan denied your request. The Plan says you have exceeded the frequency limit for periodic oral evaluations. The Plan also says that periapical radiographic images are not a covered 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation and intraoral periapical radiographic images have not been met. Specifically, the record shows that you had exceeded the frequency limit for the periodic oral evaluation on July 24, 2020, and December 16, 2020. Additionally, intraoral periapical radiographic images are not a covered benefit. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and intraoral periapical radiographic images (D0220) provided on November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the dental services (D7210, D9999) received December 1, 2020.
You asked the Plan to pay an additional amount for the dental services (D7210, D9999). You say that the plan should pay more for the dental services. The Plan denied your request. The Plan says your $775 dental benefit allowance exhausted in this claim; therefore, you are responsible for any amount over the Plan's allowed charge, billed by the provider.
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 payment is in excess of that covered under this benefit. The Plan has a $775 dental benefit allowance. Prior to the claim in dispute the Plan paid out $232 for previous claim, leaving $543 remaining in the dental allowance. For the claim on December 1, 2020 the Plan paid the remaining $543 from the allowance, leaving it exhausted. In 2020, you are responsible for any amount charged by the provider over the Plan's $775 dental allowance. Therefore, we decided that the Plan does not have to pay an additional amount for the dental services (D7210, D9999) received December 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on November 6, 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 to you by an out-of-network provider on November 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), vertical bitewings
(D0277), prophylaxis (D1110) and unspecified dental procedure (D1999) provided December 21, 2020, by an
OON provider.
You asked the Plan to pay for the oral evaluation, vertical bitewing x-rays, dental cleaning and unspecified
dental procedure. You say that it was not made clear that you need to use a network provider. The Plan denied
your request. The Plan says services are not covered by the Plan when using an OON provider.
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 oral
evaluation and dental cleaning when the services are rendered by a network provider. Vertical bitewing x-rays
and unspecified dental procedures are not covered by the Plan.
We looked at the file, and Medicare rules. You received services from an OON provider. Additionally, though
the Plan offers a dental benefit in excess of Medicare coverage, vertical bitewings and unspecified dental
procedures are not among those covered under the dental benefit. Based on this information, we decided that
the Plan does not have to pay for the periodic oral evaluation (D0120), vertical bitewings (D0277), prophylaxis
(D1110) and unspecified dental procedure (D1999) provided December 21, 2020, by an OON provider.
Your complaint about the information about coverage from the Plan not being as clear about limitations as you
believe it should be 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.