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

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0427, A0425) provided August 30, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $270 copayment for Ambulance Services. You have been asked to pay a $270 copayment for the ambulance transport. The ambulance transport 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 an ambulance transport (A0427, A0425) provided August 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L0650) provided September 29, 2020.

You asked the Plan to pay for the orthosis. You say that the orthosis was medically necessary. The Plan denied
your request. The Plan says the documentation does not support the item 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 code L0650 is not supported in the medical record. Specifically, the plan has attested that
there is no record of an in-person or telephonic visit with the ordering physician in the enrollee's claim history.
Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.
Therefore, we decided that the Plan does not have to pay for an orthosis (L0650) provided September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic treatment provided on November 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the chiropractic treatment. You say that you are filing an earnest appeal concerning the services rendered. The Plan denied your request. The Plan says the provider is out of 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 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 chiropractic treatment provided on November 24, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 16, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because this testing was medically necessary due to the mercury mines in your area and mercury levels in the water. The Plan denied your request. The Plan says there is no record of prior authorization being obtained for the billed services.
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 laboratory services provided on September 16, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care visit provided on October 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care visit. You say that the service is 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 nursing facility care visit provided on October 14, 2020 by an out of network (OON) provider.
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 December 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.
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 December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided on September 9, 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 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 nursing facility visit provided on September 9, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99308) provided on November 17, 2020.
You asked the Plan to pay for the nursing facility care. You say that the service was medically necessary. The Plan denied your request. The Plan says the service was not emergent or pre-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 service 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 nursing facility care (99308) provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided on November 25, 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 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 nursing facility visit provided on November 25, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider on December 30, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that this was non emergent transport. 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 for ambulance services. You have been asked to pay $56.10 which is less than your copayment amount of $300 for ambulance services. Ambulance services 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 ambulance services provided by a participating provider on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D4381, D9630, D4921) provided to you on November 4, 2020.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says these services are 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 services are not among those covered under this benefit. The Plan only covers dental codes D0120, D0150, and D1110. The requested dental services, represented by codes D4381, D9630, and D4921, are not covered under your plan. Therefore, we decided that the Plan does not have to pay for the dental services (D4381, D9630, D4921) provided to you on November 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81404, 81405, 81406, 81407, 81408, 81439) provided May 30, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the service at issue is not covered under Medicare.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. We looked at the file and Medicare rules. The tests at issue are considered cardiovascular risk assessment panels and are not covered. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81404, 81405, 81406, 81407, 81408, 81439) provided May 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210) and limited (problem-focused) oral evaluation (D0140) provided on November 24, 2020.
You asked the Plan to pay for the extraction and limited evaluation. You say that you were referred to this out-of-network provider, and you still have money left in the $2,000 maximum dental allowance. You feel the Plan should reimburse you for the full cost of these services because they were necessary. The Plan denied your request. The Plan says they have reimbursed you the correct amount for the extraction, and the limited evaluation is not covered by Medicare or by the dental benefit.
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 55% coinsurance for dental extractions performed by an out-of-network provider. You may also be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider.
You paid $225 for the extraction at the time of service, and the Plan reimbursed you $47.70. The provider billed the full $225 amount, however the Plan's maximum allowed cost for an extraction is $106. This is a rate that the Plan has negotiated with in-network providers, however it has not been agreed to by out-of-network providers. You are responsible for this difference in cost. You are also responsible for 55% coinsurance for extractions provided out-of-network, which leaves the Plan responsible for 45% of the allowed cost (106 x 45% Plan's payment = $47.70). You are responsible for the remainder of the cost of the extraction because out-of-network extractions require 55% coinsurance, and you are responsible for the additional cost that the provider billed above the Plan's maximum allowed charge. This means the Plan has reimbursed you 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 provide additional reimbursement for the extraction (D7210) provided on November 24, 2020.
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 can cover periodic oral evaluations, periodontal exams and comprehensive oral evaluations. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested limited (problem-focused) oral evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited (problem-focused) oral evaluation (D0140) provided on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a laser neuropathy treatment (99199) provided October 27, 2020.
You asked the Plan to pay for the laser treatment. You say that this service was medically necessary. The Plan denied your request. The Plan says this treatment is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that the use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy (MIRE), is not covered. We looked at the file and Medicare rules. The requested laser treatment is not covered. Based on this information, we decided that Medicare rules for coverage of the laser treatment have not been met. Therefore, we decided that the Plan does not have to pay for a laser neuropathy treatment (99199) provided October 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewings - four radiographic images (D0274), and prophylaxis (D1110) provided October 26, 2020.

You asked the Plan to pay for the oral evaluation, bitewing x-rays and dental cleaning. You say that there aren't any dentists in your area that accept your dental plan. The Plan denied your request. The Plan says there are dental providers in your area that accept your dental benefit. Since these services were provided OON, they are 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. The Plan covers the oral evaluation, bitewing x-rays and dental cleaning when the services are provided by a network provider. 

We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan at the time of the service. We verified that 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. Based on this information, we decided that the Plan's rules for coverage of the oral evaluation, bitewing x-rays and dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewings - four radiographic images (D0274), and prophylaxis (D1110) provided October 26, 2020.

Your complaint about potentially not being provided a list of network providers upon request 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L2397, L1833) provided September 29, 2020.
You asked the Plan to pay for the knee orthosis. You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 L2397, & L1833 are not supported in the medical record. Specifically, the plan has attested that there is no documentation of a claim for an in-person or telephonic visit with the ordering physician. Based on this information, we decided that Medicare rules for coverage of the knee orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L2397, L1833) provided September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth per quadrant (D4341), unspecified preventive procedure, by report (D1999) and odontoplasty - per tooth (D9971) provided July 21, 2020, and July 30, 2020.
You asked the Plan to pay for the periodontal scaling and root planning, unspecified preventative procedure and odontoplasty. You say that you were told by a sale representative that your benefits would be the same as your previous plan's benefits. The Plan denied your request. The Plan says these services are not included in your dental 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 the periodontal scaling and root planing - four or more teeth per quadrant (D4341), unspecified preventive procedure, by report (D1999) and odontoplasty - per tooth (D9971) provided July 21, 2020, and July 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance, half leg
(CPT code E0673-NU-RT-LT) and pneumatic compression device, high pressure, rapid inflation/deflation
cycle, for arterial insufficiency (CPT Code E0675-RR) provided on November 4, 2020.
You asked the Plan to pay for the DME. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. Review of the records show that you
had shoulder surgery and these devices were used to prevent blood clots. Your doctor states in the medical
record that you had foot surgery on November 4, 2020, and this device was used to help prevent blood clots
during and after your operation. The correct coding for this device for prevention of deep venous thrombosis is
E0676. Service E0673 (segmental gradient pressure pneumatic appliance, half leg) is denying because the
DME was billed with an incorrect place of service. According to Medicare guidelines, the DME must be for
use in the enrollee's residence other than a healthcare institution and payment cannot be made for equipment
for use in an institution. The provider can resubmit a corrected claim for this service to obtain payment.
Therefore, we decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance,
half leg (CPT code E0673-NU-RT-LT) and pneumatic compression device, high pressure, rapid
inflation/deflation cycle, for arterial insufficiency (CPT Code E0675-RR) provided on November 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321) provided May 26, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not filed correctly.
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 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, and 81321 are not supported in the medical record. Specifically, this service should be billed using CPT code 81479. The service was unbundled to separate codes. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321) provided May 26, 2020.