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

We decided that the Plan does not have to pay for the bitewing x-rays (D0274).

You asked the Plan to pay for the bitewing x-rays. You say that bitewing x-rays are covered under your insurance. The Plan denied your request. The Plan says this service is not covered by the 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 bitewing x-rays (D0274).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI and the skin biopsy.

You asked the Plan to waive the copayment for the MRI and skin biopsy. You say that you were told there would be no cost if this was a preventive procedure. You say that you should not have been billed. The Plan denied your request. The Plan says the copayments applied 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 $275 copayment for advanced imaging services provided at an in-network outpatient hospital and a $365 copayment for surgery services at an in-network outpatient hospital.

You have been asked to pay a total of $567.51 for the MRI and skin biopsy.

The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The skin biopsy 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 the MRI and the skin biopsy.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport.

You asked the Plan to waive the copayment for the ambulance transport. You say that you were informed you had to be transferred by ambulance. You say that you shouldn't have been forced to take the ambulance if it was going to result in such a high cost. The Plan denied your request. The Plan says the copayment applied 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 $325 for Medicare-covered ambulance services per trip.

You have been asked to pay a $325 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show you were transported by ambulance to the hospital. 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 transport.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses.

You asked the Plan to pay for eyeglasses. You say that you were not aware that the location you purchased the eyeglasses was not part of the Plan's vision service vendors. The Plan denied your request. The Plan says you did not use the Plan's vision vendor and therefore, it is not a covered service.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when you utilize the Plan's vision services vendor.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Specifically, the eyeglasses were not purchased through the Plan's supplemental vision benefits vendor. Therefore, we decided that the Plan does not have to pay for eyeglasses.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray.

You asked the Plan to waive the copayment for the chest x-ray. You say that you would have gone to a different location if you knew you would have to pay a high copayment. The Plan denied your request. The Plan says the copayment applied 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 $125 copayment for x-rays and ultrasounds in an outpatient hospital setting.

You have been asked to pay $119.20, which is less than the standard $125 copayment for the chest x-ray. The chest x-ray falls 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 copayment for the chest x-ray.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing services.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services are not necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We find that the testing at issue is not supported in the medical record. The records provided do not show that the testing was ordered as part of a specific treatment strategy. 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 CxBladder testing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental pneumatic appliance to be provided by the out-of-network provider.

You asked the Plan to pre-approve the pneumatic compressor, segmental pneumatic appliance. The Plan denied your request. The Plan says the medical record received did not show that you have an emergent or urgent medical condition or are in need of specialized service(s) that are not available in the network. There are in-network provider(s) within a reasonable distance from your location that can provide this item/service.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor, segmental pneumatic appliance to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) and problem focused limited oral evaluation (D0140) provided on October 21, 2020.

You asked the Plan to pay for the preventive procedure and problem focused limited oral evaluation. You say that you would like these services to be covered. The Plan denied your request. The Plan says the preventive procedure is not a covered benefit under your dental plan. The Plan also says that the problem focused limited oral evaluation service exceeds the frequency limitation in your benefit 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 unspecified preventive procedure is not among those covered under this benefit. The contract also clearly states that problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on August 21, 2020, and your problem focused limited oral evaluation (D0140) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the preventive procedure (D1999) and problem focused limited oral evaluation (D0140) provided on October 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan.

You asked the Plan to waive the copayment for the CT scan. You say that you didn't get a full CT scan and your doctor didn't get a copy of the report. You say that you shouldn't have to pay. The Plan denied your request. The Plan says the copayment applied 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 $200 copayment for advanced imaging services.

You have been asked to pay a $200 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the CT scan was performed. 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 CT scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that these items were medically necessary. The Plan denied your request. The Plan says there is no established relationship between the prescribing physician and the enrollee.

The Plan follows Medicare rules. Medicare rules say that the 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 knee orthosis and suspension sleeve. Our reviewer says that the requested items are not medically necessary and reasonable. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291, 80047, 80053, 87804, 85380, 85025, 36000, D9630).

You asked the Plan to pay for critical care services. You say that these services should be covered. The Plan denied your request. The Plan says this claim was received outside of the timely filing limit.

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 critical care services was not filed until December 4, 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 critical care services (99291, 80047, 80053, 87804, 85380, 85025, 36000, D9630).
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 request that you only have to pay a $10 copayment not a $45 copayment. 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 $50 copayment for each specialist visit.

You have been asked to pay a $50 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for laboratory services.

You asked the Plan to waive the coinsurance for laboratory services. You say that you did not know you would owe such a high copayment. 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 50% coinsurance for out-of-network outpatient diagnostic tests and therapeutic services and supplies.

You received laboratory services from an out-of-network provider. Therefore, you are responsible to pay $252.67, which is less than the 50% coinsurance amount.

You have been asked to pay $252.67 for laboratory services. Laboratory services 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 coinsurance for laboratory services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan.

You asked the Plan to waive the copayment for the duplex scan. You say that you already paid your specialist office visit copayment. You say that you don't understand why you're getting an additional $20 copayment. The Plan denied your request. The Plan says the copayments applied 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 $20 copayment per visit for laboratory tests, non-radiological tests, diagnostic tests, flat film x-rays, and ultrasounds.

You have been asked to pay a $20 copayment for each duplex scan. The total amount you owe is $40 ($20/visit x 2 visits = $40). The duplex scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 duplex scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure and additional intraoral periapical x-ray, or pay more for the periodic oral evaluation, first intraoral periapical x-ray, bitewing x-rays, and prophylaxis provided by an OON provider.

You asked the Plan to pay for the preventive procedure and additional intraoral periapical x-ray, and pay more for the periodic oral evaluation, first intraoral periapical x-ray, bitewing x-rays, and prophylaxis. You say that you would like these services to be covered. The Plan denied your request. The Plan says the preventive procedure is not a covered benefit. The Plan says that your benefits for the additional intraoral periapical x-ray had been satisfied and the frequency limitation had been exceeded. The Plan also says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the 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, unspecified preventive procedure is not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray and your intraoral x-rays benefit had been exhausted. The Plan contract also clearly states that you will be responsible for the difference between the billed amount and allowed amount, plus the coinsurance, for services received OON. Therefore, we decided that the Plan does not have to pay for the preventive procedure and additional intraoral periapical x-ray, or pay more for the periodic oral evaluation, first intraoral periapical x-ray, bitewing x-rays, and prophylaxis provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (98941).

You asked the Plan to pay for chiropractic services. You say that this should be covered. The Plan denied your request. The Plan says this was non-covered maintenance care.

The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care.

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 chiropractic services. Our reviewer says that the chiropractic services at issue are chiropractic maintenance care. Our physician reviewer found the medical records document subjective complaints of moderate dull and aching pain with muscle spasms and tightness. Objective findings throughout include tolerable pain and subluxations. The assessment includes segmental and somatic dysfunctions and low back pain. These complaints, findings, and assessments are found throughout the documented care. There is no evidence that any clinical improvement has occurred from continuous ongoing care or that any future clinical improvement would likely occur.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan does not have to pay for chiropractic services (98941).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ketamine infusions provided by an out of network (OON) provider.

You asked the Plan to pay for the Ketamine infusions. You say that please review all attachments and submit this claim for payment. The Plan denied your request. The Plan says this type of therapy is experimental and/or unproven. Enrollee's must receive their medical services from an in-network provider. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 Ketamine infusions provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transports from dialysis and physician office to residence.

You asked the Plan to pay for the non-emergent ambulance transports. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee appears to be able to sit in a wheelchair or recliner therefore alternatives to transport may include a wheelchair van or a private vehicle.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

We looked at the file and Medicare rules. The record shows the enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. The enrollee could have been safely transported by another type of vehicle. You did not request prior authorization. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance transports have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transports from dialysis and physician office to residence.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the measles, mumps, and rubella (MMR) vaccine rendered.

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 are not covered.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules.

The file does not show that you have been injured or directly exposed to any illness related to the MMR vaccine. Therefore, we decided that the Plan does not have to pay for the measles, mumps, and rubella (MMR) vaccine rendered.

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.