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

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on April 24, 2020.

You asked the Plan to waive the copayment for the ambulance ride. You say that there should be no charge for any transportation during an emergency. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for each one way trip. 

The enrollee has been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance ride provided on April 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the prosthetic device provided on August 5, 2020.

You asked the Plan to waive the coinsurance for the prosthetic device. You say that you should not be billed for services you cannot use. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 20% coinsurance for each in-network Medicare-covered prosthetic device. 

You have been asked to pay a total of $1,977 which is 20% of the total allowed amounts for the prosthetic device. The prosthetic device falls within the "Prosthetic devices and related supplies" benefit category. See chart below.

Date of Service          Service                                    Allowed Amount           Coinsurance       Member Liability
August 5, 2020      Prep below knee PTB socket             $2,056.55                       20%                 $411.31
August 5, 2020      S/A, below knee                                  $297.56                       20%                  $59.51
August 5, 2020      Addition to lower extremity                   $384.40                       20%                  $76.88
August 5, 2020      BK Flex inner socket ext fra                 $977.86                       20%                $195.57
August 5, 2020      BK/AK locking mechanism                   $496.41                       20%                 $99.28
August 5, 2020      Socket insert with lock mechanism    $1,577.88                        20%               $315.58
August 5, 2020      Addition, endoskeletal system              $361.44                        20%                 $72.29
August 5, 2020      Addition, endoskeletal system              $500.60                        20%               $100.12
August 5, 2020      All lower extremity prosthesis            $3,425.06                        20%                $646.46 - This is
                                                                                                                                            less than the 
                                                                                                                                        standard 20% amount
Total                                                                                                                                      $1,977.00

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 the prosthetic device provided on August 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the chest x-ray provided on October 23, 2020.
You asked the Plan to waive the copay for the services provided. You say that you were under the impression the copay would be waived. The Plan denied your request. The Plan says the claim was 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 $25 copay for each Medicare-covered x-ray service. You have been asked to pay a $25 copay for the services provided. The services fall within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the chest x-ray provided on October 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic mammogram and tomosynthesis services provided on August 17, 2020.
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says the services were previously approved and paid.
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 at issue were previously processed and paid for by the Plan. The records provided do not indicate the enrollee received separate and distinct services on the date of service at issue. 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 diagnostic mammogram and tomosynthesis services provided on August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on October 27, 2020.

You asked the Plan to pay for the dental services. You say that you called the Plan prior to having the services provided. You also say that you were told it was covered. The Plan denied your request. The Plan says surgical extractions are 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 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 surgical extraction (D7210) provided on October 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 22, 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 June 22, 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 June 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide services (S9122) provided on June 3, 2020.


You asked the Plan to pay for the home health aide services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service has not been billed 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 code S9122 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9122 has a status indicator of I. This means that CPT code S9122 is not valid for Medicare purposes. Additionally, this claim was not billed with the required Q code. Based on this information, we decided that Medicare rules for coverage of the home health aide services have not been met. Therefore, we decided that the Plan does not have to pay for the home health aide services (S9122) provided on June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3320), crown (D2750), and core build up (D2950) provided on September 21, 2020.

You asked the Plan to pay for the dental services. You say that you had to have emergency dental work done. You say that the Plan should cover more than $50.50 of the total amount. The Plan denied your request. The Plan says there is a $1,000 allowance every year for nonMedicare covered preventive and comprehensive dental services combined. The Plan says that the allowance has been exhausted. The Plan also says you are responsible for any amount above the dental coverage limit.

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 annual allowance of $1,000 for preventive and comprehensive dental services has been exhausted. The record shows that the Plan paid $949.50 for dental services that you received on January 16, 2020 and $50.50 for the dental services that you receive don September 12 2020, thus exhausting the annual allowance. Additionally, the Evidence of Coverage clearly states that you are responsible for any amount above the dental coverage limit. Therefore, we decided that the Plan does not have to pay for the root canal (D3320), crown (D2750), and core build up (D2950) provided on September 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 30, 2020.

You asked the Plan to pay for the dental service. You say that this service was an emergency. You say that your tooth has a cap on it but there is decay underneath that is causing pain. You say that you want to avoid large crowds due to the pandemic, but the pain was too much and you needed to see the doctor. You also say that you have postponed the service to replace the temporary cap. The Plan denied your request. The Plan says 1 limited oral evaluation per plan year is covered. The Plan also says that the frequency limit 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, the frequency limit of 1 limited oral evaluation per plan year has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on April 9, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on July 29, 2020.

You asked the Plan to waive the copayment for the endoscopy. You say that you would appreciate if insurance would cover this $325 because this is a lot of money for you. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $325 copayment for each in-network Medicare-covered ambulatory surgical center visit. 

You have been asked to pay a $325 copayment for the endoscopy. The endoscopy 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 endoscopy provided on July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 13, 2018.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the requested documentation was not received timely.
The Plan must follow Medicare rules. Medicare rules say that MACs shall deny claims when the requested documentation to support payment is not received by the expected timeframe. We find that additional documentation requested by the Plan was not received in a timely fashion. 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 medical services provided on July 13, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99310) provided on May 28, 2019.
You asked the Plan to pay for subsequent nursing facility care. You say that you provided medically necessary services in good faith. The Plan denied your request. The Plan says the claim was received past the twelve month deadline.
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 subsequent nursing facility care was not filed until August 28, 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 subsequent nursing facility care (99310) provided on May 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for CYSTOSCOPY AND TREATMENT (52224) and tissue exam (88305) provided on October 12, 2020.
You asked the Plan to waive the copayment for tissue exam, cystoscopy and treatment. You say that the services should be covered. The Plan denied your request. The Plan says the cost share was 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 $400 copayment for outpatient hospital observation. You have been asked to pay a $400 copayment for tissue exam, cystoscopy and treatment. These services fall within the outpatient hospital observation 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 CYSTOSCOPY AND TREATMENT (52224) and tissue exam (88305) provided on October 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient rehabilitation facility (IRF) services provided on January 15, 2020 to February 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for IRF services. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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 inpatient rehabilitation facility (IRF) services provided on January 15, 2020 to February 7, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT Scan of the head (70450) provided on August 27, 2020.
You asked the Plan to pay for the CT Scan of the head. You say that you would like reconsideration because the member had multiple exams on the same date of service. The Plan denied your request. The Plan says the submitted documentation supports 1 unit of 70450-26-77, which was previously approved/paid.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT Scan of the head have not been met. Specifically, the documentation submitted indicates that one unit of 70450 was rendered by this provider on the billed date of service. The record indicates that this service has been approved and paid by the Plan. Therefore, we decided that the Plan does not have to pay for the CT Scan of the head (70450) provided on August 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the lab services provided on September 9, 2020.
You asked the Plan to waive the copay for the lab services. You say that the blood was drawn at the doctor's office. The Plan denied your request. The Plan says the claim 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 $20 copay for lab services in a freestanding laboratory. You have been asked to pay a $20 copay for the lab services. The services fall within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the lab services provided on September 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical x-ray (D0230 x 2), and the filling (D2335) provided from August 6, 2020, to August 14, 2020.
You asked the Plan to pay for the dental services. You say that the book says that fillings and x-rays are covered. You say that you feel the enrollment guide is deceptive when it says something is covered and then the claim gets denied. The Plan denied your request. The Plan says periapical x-rays are not listed as covered services. The Plan says the filling is not listed as a covered service. The Plan also says you are responsible for paying the full cost of services that are 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. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical x-ray (D0230 x 2), and the filling (D2335) provided from August 6, 2020, to August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the documents prove medical necessity. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 documentation shows the enrollee was seen for chronic back pain. The 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 medical services provided on May 21, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the physician depends on the hospital staff to obtain the proper authorization. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers.
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 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 medical services provided on July 17, 2020 by an out of network (OON) provider.