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

We decided that the Plan does not have to pay for the ambulance services provided on January 1, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 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 January 1, 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 January 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services with CPT codes A0427 and A0425 provided on February 28, 2020.
You asked the Plan to pay for CPT codes A0427 and A0425. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare says ambulance claims need to be edited to assure the presence of an origin, destination modifier, and a QM or QN modifier for every line item containing revenue code 540. The file shows that the claim was not billed with either a QM or QN modifier. Therefore, we decided that the Plan does not have to pay for the ambulance services with CPT codes A0427 and A0425 provided on February 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 2, 2020, to August 20, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from February 25, 2020, to August 1, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 2, 2020, to August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood bank physician services rendered on June 18, 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 services are not covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 86077 is 1. You billed 2 units of this code, exceeding the MUE. 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 blood bank physician services rendered on June 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 3, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. 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 August 3, 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 August 3, 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 May 21, 2020, to May 28, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with these charges. 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 $390 copayment per day for days 1-5 for inpatient hospital care. You have been asked to pay a $390 copayment per day for days 1-5 for an inpatient hospital stay. The total amount you are being asked to pay is $1,950 ($390 x 5 days = $1,950). An inpatient hospital stay falls within the inpatient hospital care 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 May 21, 2020, to May 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction provided on April 30, 2020.
You asked the Plan to pay for the surgical extraction. You say that your copay should be waived because you already paid your portion for the tooth extraction. You also say that you are now being billed for services that are not being explained to you. The Plan denied your request. The Plan says you reached your maximum allowance of $1,000 for dental services prior to this claim being received.
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 Plan offers coverage of $1,000 per year. The contract says that you are responsible for any amount above the $1,000 dental maximum per calendar year. The record shows that you met the annual maximum benefit while processing a claim for the July 22, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the surgical extraction provided on April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for injections (20610) provided August 3, 2020.
You asked the Plan to waive the copayment for the injections. 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 $200 copayment for outpatient surgical services. You have been asked to pay a $200 copayment for the injections. The injections fall within the outpatient surgical 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 injections (20610) provided August 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an abdominal aortic aneurysm screening ultrasound received on August 7, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there is no indication the enrollee contacted the plan prior to verify benefit coverage.
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the contract language is vague concerning the indications for the exam, with the term "at risk" difficult to quantitate. CMS guidelines typically require either a very strong family history of abdominal aortic aneurysm or a patient 65 years of age or older with a smoking history. Review of the enclosed materials revealed no clinical information with which to make the determination of "significant risk". There is no further information with which to make any determination. There is no report of the exam and a written order is not appreciated; both these pieces of information are also required for reimbursement. 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 services have not been met. Therefore, we decided that the Plan does not
have to pay for an abdominal aortic aneurysm screening ultrasound received on August 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the denture adjustment (D5640) provided on July 28, 2020.
You asked the Plan to pay for the dental service. You say that you had a tooth replaced that was missing on your bridge. You also say that per page 4-59 of your Evidence of Coverage this claim should be covered. The Plan denied your request. The Plan says that page 4-59 lists services related to bridges. The Plan says that the denture adjustment is not listed as a covered service. The Plan also says that any services not listed 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the denture adjustment (D5640) provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 18, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can requireenrollees 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 physician's services. 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 physician's services provided on August 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided.

You asked the Plan to pay for the ambulance services. You say that this service is covered.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 pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. 


The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.Therefore, we decided that the Plan does not have to pay for the ambulance services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for intravenous infusion, for therapy, prophylaxis, or diagnosis (96365) injection, natalizumab, 1 mg (J2323) infusion, normal saline solution, 250 cc (J7050) provided July 1, 2020.
You asked the Plan to waive the coinsurance for the infusion services. You say that over the past several years your copay for infusion has been $95. Now it is $715.27. This is very unattainable for your fixed income and could result in discontinuation of a medicine. 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 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 17% coinsurance for in-network Medicare part B Covered drugs. You have been asked to pay $715.27 ($4,207.44 x 17%) for the infusion services. The infusion services fall within the Medicare Part B prescription drugs 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 intravenous infusion, for therapy, prophylaxis, or diagnosis (96365) injection, natalizumab, 1 mg (J2323) infusion, normal saline solution, 250 cc (J7050) provided July 1, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from June 16, 2020, to July 31, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient SNF level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from June 16, 2020, to July 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography (95868) provided May 15, 2020.
You asked the Plan to pay for the needle electromygraphy. You say that you are submitting medical records for review to support the billing of procedures as medically necessary. The Plan denied your request. The Plan says the diagnosis code reported on the claim as H90.3 does not support medical necessity for CPT 95868.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The diagnosis code is not listed on the Local Coverage Article: Billing and Coding: Nerve Conduction Studies and Electromyography (A540895) as a code that supports medical necessity. Based on this information, we decided that Medicare rules for coverage of the needle electromygraphy have not been met. Therefore, we decided that the Plan does not have to pay for the needle electromyography (95868) provided May 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for the two extractions and one surgical extraction provided on June 24, 2020, and July 7, 2020.
You asked the Plan to make additional payment for the extractions. You say that you needed emergency dental care, and were referred to a clinic nearby. You also say that you went to this provider because you needed service during the general shutdown, and routine dental care was unavailable. The Plan denied your request. The Plan says the benefits for the third extraction have been satisfied and the frequency limitation has been exceeded.
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, extractions are limited to two procedures per calendar year, and you are responsible for a 50% coinsurance when the extractions are provided in-network. The record shows that you received 3 extractions from June 24, 2020, to July 7, 2020, two of which were covered by the Plan at the in-network rate, and your extractions benefit has been exhausted. You are responsible for a 50% coinsurance for the two covered extractions. Therefore, we decided that the Plan does not have to make additional payment for the two extractions and one surgical extraction provided on June 24, 2020, and July 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor supplies rendered on August 21, 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 physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 continuous glucose monitor supplies rendered on August 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on November 5, 2019.
You asked the Plan to waive the copayment for the eye exam. You say that you never had a copayment for an exam before. The Plan denied your request. The Plan says you were charged this copayment 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. You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the 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 eye exam provided on November 5, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided on April 24, 2019.
You asked the Plan to pay for the inpatient hospital services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 the inpatient hospital services was not filed until August 3, 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 the inpatient hospital services provided on April 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a comprehensive metabolic panel (80053) provided on September 10, 2020.
You asked the Plan to waive the copayment for a comprehensive metabolic panel. You say that this should be covered as part of an office visit. The Plan denied your request. The Plan says this 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 $10 copayment for Medicare-covered laboratory tests. You have been asked to pay a $10 copayment for a comprehensive metabolic panel, which is a Medicare-covered laboratory test. 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 comprehensive metabolic panel (80053) provided on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) and clinical crown lengthening (D4249) provided on July 22, 2020.
You asked the Plan to pay for the bitewing x-rays and clinical crown lengthening. You say that you had a toothache. You say that you went to the dentist to have it fixed. You also say that you did not know what else to do when having a toothache, other than seeing a dentist. The Plan denied your request. The Plan says one bitewing x-ray procedure per plan year is covered. The Plan says that the frequency limit has been exceeded. The Plan also says that clinical crown lengthening is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 bitewing x-ray procedure per plan year has been exceeded. The record shows that the Plan paid for bitewing x-rays that you received on February 4, 2020. Additionally, clinical crown lengthening is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) and clinical crown lengthening (D4249) provided on July 22, 2020.