Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the initial hospital care (99222) provided May 7, 2020.
You asked the Plan to waive the deductible for the hospital care. You say that you are unable to complete the deductible. The Plan denied your request. The Plan says the claim was processed correctly with your cost being applied to your deductible.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $150 deductible for covered medical services. The item or service you asked the Plan to waive the deductible for falls within the benefit category Inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time the hospital care was received on May 7, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the initial hospital care (99222) provided May 7, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after August 22, 2021.
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that that you no longer require skilled services on a daily basis as you remain non-weight bearing and the continuation of SNF is not medically necessary.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before August 22, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after August 22, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care discharge day management (99217) provided on March 16, 2021 by an OON provider.

You asked the Plan to pay for the observation care discharge day management. You say that no authorization or referral was needed. The Plan denied your request. The Plan says the services were rendered by a non-network provider. The Plan also says that the services were not referred by a 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 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 observation care discharge day management (99217) provided on March 16, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7210) for tooth # 4 provided on February
26, 2021.
You asked the Plan to pay for the extraction for tooth # 4. You say that you received a bill from your dental
office for $5,800. The Plan denied your request. The Plan says 6 extractions are covered every 1 calendar year.
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 and extractions are listed as covered,
the frequency limit has been exceeded. The record shows that the Plan paid for the extractions for teeth # 5, 12,
18, 19, 20, and 21 that you received on February 26, 2021. Therefore, we decided that the Plan does not have to
pay for the extractions (D7210) for tooth # 4 provided on February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve panniculectomy with a back lift.
You asked the Plan to pre-approve the surgery. You say that you are in severe pain, have rashes and sores underneath your stomach. The Plan denied your request. The Plan says the medical records provided did not show that your symptoms were refractory to the usual standard medical therapy. The Plan states they requested notes and pictures from your plastic surgeon to show that you meet the criteria but did not receive them.
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 surgery have not been met. There is not enough clinical information provided to verify if you meet criteria. The Plan states they requested notes and pictures from your plastic surgeon to show that you meet the criteria but did not receive them. Therefore, we decided that the Plan does not have to pre-approve panniculectomy with a back lift.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic consultation with a dentist or physician other
than the requesting dentist or physician (D9310) and an unspecified preventative procedure (D1999) provided
on April 19, 2021.
You asked the Plan to pay for the dental services. You say that these services were necessary, and you feel they
must have been billed incorrectly because your benefit covers dental exams. The Plan denied your request. The
Plan says these services are not covered by 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. While some exams are covered by your benefit, a diagnostic
consultation is not the same service as the types of exams your benefit covers. Therefore, we decided that the
Plan does not have to pay for the diagnostic consultation with a dentist or physician other than the requesting
dentist or physician (D9310) and an unspecified preventative procedure (D1999) provided on April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, endodontic therapy, treatment of root canal obstruction and pulp vitality tests provided on May 5, 2021.
You asked the Plan to pay for the limited oral evaluation, endodontic therapy, treatment of root canal obstruction and pulp vitality tests. You say that you only had two crowns and two root canals which are covered. You say that all crowns, root canals and fillings are covered. The Plan denied your request. The Plan says the claim processed correctly.
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, you also have a maximum benefit of two diagnostic exams per calendar year and one root canal per calendar year. The Plan paid for diagnostic exams provided on April 8, 2021 and April 5, 2021 and a root canal provided on April 8, 2021, which exhausted your benefits. The root canal obstruction and pulp vitality tests are not listed as covered benefits. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation, endodontic therapy, treatment of root canal obstruction and pulp vitality tests provided on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-of-network (OON) provider on March 1, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 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 laboratory services (88305, 88312) rendered by the out-of-network (OON) provider on March 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307, G0482) rendered by the out-of-network (OON) provider on February 24, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the drug testing (80307, G0482) rendered by the out-of-network (OON) provider on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5298) purchased on January 13, 2021,
from an out-of-network provider.

You asked the Plan to pay for the hearing aids. You say that you lost one hearing aid and needed a new pair.
You did not know you had to go through a specific vendor and feel that you would not have received the
hearing aids quickly enough if you had. The Plan denied your request. The Plan says the hearing aids were
purchased out-of-network. Hearing aids ordered through providers other than the Plan's specified vendor are
not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when they are purchased through the specified network vendor.

We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that
the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does
not have to pay for the hearing aids (V5298) purchased on January 13, 2021, from an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the $142.77 copayment charged for an ultrasound provided on
April 15, 2021.
You asked the Plan to waive this copayment. You say that you feel this ultrasound was not necessary and you
do not feel you owe the copayment. The Plan denied your request. The Plan says this copayment was charged
based on the claim submitted by the provider and the Plan contract agreement.
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 $160
copayment for outpatient radiology services. In this case you have been asked to pay less than the normal
copayment. The Plan has paid its share of this service. 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 $142.77
copayment charged for an ultrasound provided on April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three resin-based composites provided on May 13, 2021.
You asked the Plan to pay for the resin-based composites. You say that you believe these services are covered because you have only received two crowns and two root canals. The Plan denied your request. The Plan says benefits for these services 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, restorations (fillings) are limited to two procedure codes per calendar year. The record shows that you received two resin-based composites on May 4, 2021 and your restorations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the three resin-based composites provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3330) on tooth # 14 provided on October 1,
2020.
You asked the Plan to pay for the dental service. You say that you should be reimbursed 50% for this service as
stated in the policy. The Plan denied your request. The Plan says root canal 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 root canal is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the root canal (D3330)
on tooth # 14 provided on October 1, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on April 8, 2020.
You asked the Plan to pay for home health services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says this claim denied because according to Medicare Claims Processing Manual, Chapter 10-Home Health Agency Billing, claims are required to be billed on the Original Medicare form which is CMS-1450, also known as the UB-04. In addition, code S9122 is assigned a status code = I, which is not payable on Medicare claims.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and submit claims on the appropriate claim forms. In this case, this claim was submitted on the incorrect form with a statutorily excluded code under Medicare. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee on April 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 21, 2020.

You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on September 21, 2020 and received by the lab on September 24, 2020.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case this claim cannot be paid as billed due to an issue with the POS codes billed. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam image capture (D0364), pulp vitality tests (D0460), pulpal debridement (D3221) and endodontic therapy (D3330) provided on March 26, 2021 to April 14, 2021.
You asked the Plan to pay for the dental services. You say that you cannot afford these costs and you feel you were misled about your dental coverage because your Plan told you this was the best dental option. The Plan denied your request. The Plan says a cone beam image captures, pulp vitality tests and pulpal debridement are not covered by your dental benefit under any normal circumstances. The Plan paid part of the cost for the endodontic therapy, but you met your $1,000 annual maximum for comprehensive dental care at this point, and no further payment will be made.
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 up to $1,000 for supplemental dental services per year, and will only cover the specific services and codes listed in the contract. 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, or exceed your annual maximum of $1,000. Therefore, we decided that the Plan does not have to pay for a cone beam image capture (D0364), pulp vitality tests (D0460), pulpal debridement (D3221) and endodontic therapy (D3330) provided on March 26, 2021 to April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120), prophylaxis (D1110), and the panoramic x-ray (D0330) provided on January 11, 2021.
You asked the Plan to pay for the dental services. You say that you found out that you had 2 insurances that cover dental services. You also say that if this is the case, you expect to collect benefit from both insurances.
The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that out of network dentists may bill you for any amount greater than what the plan pays.
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 and the services are listed as covered, out of network dentists may bill you for any amount over what the Plan paid.
Cost sharing is a contractual obligation under the plan and cannot be waived. Therefore, we decided that the Plan does not have to pay for the oral evaluation (D0120), prophylaxis (D1110), and the panoramic x-ray (D0330) provided on January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home oxygen and a portable
oxygen concentrator.
You asked the Plan to pre-approve home oxygen and a portable oxygen concentrator.
You say that these items are medically necessary. The Plan denied your request. The Plan
says that when receiving Hospice services your Part A and Part B services related to your
terminal prognosis are paid for by Original Medicare not the Plan.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered
non-hospice services. Medicare hospice pays for claims related to the terminal
illness. The rules say that the Plan may direct the provider to bill Medicare directly for
these services.
The enrollee was under the Medicare hospice benefit when the request was made.
Therefore, we decided that the Plan does not have to pre-approve home oxygen and a
portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the single-surface filling for a posterior
tooth (D2391), the 2-surface filling for an anterior tooth (D2331), and the 3-surface filling for a posterior tooth
(D2393) provided on March 11, 2021.
You asked the Plan to pay the in network rate for the dental services. You say that you have to rely on other
people for transportation to appointments. You say that the radiologist would not move forward with your
treatment until your dental work was completed. You say that you need molars back in your mouth so you can
chew. You also say that you want these services to be covered as in network. The Plan denied your request.
The Plan says that minor restorative services, such as fillings, are not listed as covered 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, the fillings are not among those
covered under this benefit, regardless of the provider's network status. Therefore, we decided that the Plan does
not have to pay the in network rate for the single-surface filling for a posterior tooth (D2391), the 2-surface
filling for an anterior tooth (D2331), and the 3-surface filling for a posterior tooth (D2393) provided on March
11, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management; more than 30
minutes (99239) provided on October 18, 2020.
You asked the Plan to pay for the hospital discharge day management. You say that the services are medically
necessary. The Plan denied your request.
The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage
of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.
The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services
and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the hospital discharge day management; more than 30
minutes (99239) provided on October 18, 2020.