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

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on April 22, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, and an intraoral complete series of radiographic images. You say that you went to an in-netowrk provider and you want the Plan to pay for the services. The Plan denied your request. The Plan says the services are a covered benefit, but you have exceeded the frequency limit of one every 3 Plan years.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, and an intraoral complete series of radiographic images have not
been met. Specifically, the record shows that you had exceeded the frequency limit prior to these services on March 3, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for chiropractic services provided from January 6, 2021, to March 6,
2021.
You asked the Plan to pay for chiropractic services. You say that these services should be covered by the Plan.
The Plan denied your request. The Plan says while services directly related to manual manipulation of the spine
were paid, those chiropractic services not allowed by Medicare cannot be covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation. The records show that the unpaid services at issue
were not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for all of
the chiropractic services provided from January 6, 2021, to March 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-emergent ambulance transportation services (A0428, A0425) provided on March 22, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you feel the Plan should pay a greater amount for these services because they were requested by your provider. The Plan denied your request. The Plan says ambulance services require a $290 copayment per date of service, regardless of the number of trips provided. Your 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 $290 copayment for ambulance services. This copayment applies per date of service regardless of the number of trips.
You have been asked to pay a $286.18 copayment for the ambulance services. 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 non-emergent ambulance transportation services (A0428, A0425) provided on
March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on May 14, 2020.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on May 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implants (D6010 x 2), bone graft at time of implant placement (D6104 x 2), second stage implant surgery (D6011 x 2), custom fabricated abutment (D6057 x 2), abutment supported crown (D6058 x 2), and an overdenture (D5865).
You asked the Plan to pre-approve the dental services. You say that the requested services are medically necessary. You say that the enrollee's medical history may lead to dental infections, poor wound healing and dental complications. The Plan denied your request. The Plan says the requested services are not listed as 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 pre-approve the implants (D6010 x 2), bone graft at time of implant placement (D6104 x 2), second stage implant surgery (D6011 x 2), custom fabricated abutment (D6057 x 2), abutment supported crown (D6058 x 2), and an overdenture (D5865).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on February 17, 2021.
You asked the Plan to waive the copayment for an office visit. You say that you were told that this was an annual wellness visit. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for primary care provider visits. The medical records show that you had an office visit that went beyond an annual wellness exam on February 17, 2021. Therefore, you are responsible to pay the $20 copayment.
You have been asked to pay a $20 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on February 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from the IRF care which cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says under Medicare, the request is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Breztri Aerosphere Inhaler (J3535).
You asked the Plan to pre-approve a Breztri Aerosphere Inhaler. You say that the enrollee cannot take other medications. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Breztri Aerosphere Inhaler (J3535).
Benefits for a Breztri Aerosphere Inhaler may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on April 28, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you contacted the Plan on May 26, 2021 and were advised that the provider was removed from the approved list that day. The Plan denied your request. The Plan says the provider who performed these services is not in the Plan's network. The Plan also says that you must use network providers to receive dental 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 requested items or services are not
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on April 28, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft (D4263) for teeth # 6 and 10, and osseous surgery (D4261) for the upper left and upper right quadrants.
You asked the Plan to pre-approve the dental services. You say that your mouth has started bleeding. You say that you need these services to be covered. You also say that you do not want to lose a tooth or teeth. The Plan denied your request. The Plan says bone replacement graft is not listed as a covered service. The Plan says that osseous surgery is not listed as a covered service either.
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 bone replacement grafts and osseous surgery are not among those covered under this benefit. Therefore, we decided that the Plan does
not have to pre-approve a bone replacement graft (D4263) for teeth # 6 and 10, and osseous surgery (D4261) for the upper left and upper right quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete upper denture (D5110), a reline of a compete lower denture (D5751), and a consultation (D9310) provided on April 19, 2021.
You asked the Plan to pay for a complete upper denture, a reline of a compete lower denture, and a consultation. You say that you were told the services would be covered. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider. A consultation is not a covered 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a complete upper denture, a reline of a compete lower denture, and a consultation have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. We found no exception that would require the Plan to pay for these services. Additionally, a consultation is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a complete upper denture (D5110), a reline of a compete lower denture (D5751), and a consultation (D9310) provided on April 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on February 17, 2021.
You asked the Plan to waive the copayment for an MRI. You say that the charges should not apply toward the deductible. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay an $5,000 deductible for outpatient diagnostic tests and therapeutic services and supplies. You received an MRI on February 17, 2021. The record shows that you had only paid $987.50 toward the $5,000 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $1,706. You have been asked to pay the deductible amount of $1,706 for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI provided on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the drug testing services provided on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and outpatient hospital clinic visit provided on August 19, 2020 by out-of-network (OON) providers.
You asked the Plan to pay for the office visit and the outpatient hospital clinic visit. You say that you were not aware the provider was not in-network when you completed this follow-up visit. 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 office visit and outpatient hospital clinic visit provided on August 19, 2020 by out-of-network (OON) providers.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99222) provided on March 15, 2020.
You asked the Plan to pay for the initial hospital care. You say that you did not receive proper notice of the enrollee's benefit determination and you depend on the facility for timely notification of enrollee's health insurance coverage. The Plan denied your request. The Plan says the time limit for filing the claim has expired. The Plan also says that this claim was received on April 14, 2021 which is past the allowed 12-month timeframe.
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 initial hospital care was not filed until April 14, 2021. 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 initial hospital care (99222) provided on March 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for CT scans and to waive the coinsurance for Medicare Part B drugs provided from January 11, 2021, to February 8, 2021.
You asked the Plan to waive the copayments for CT scans and to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the charges because you were not informed of the injections. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 copayment for CT scans. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B drugs. You received CT scans on January 11, 2021, and January 25, 2021. Therefore, you are responsible to pay a $175 copayment per each CT scan. The total amount you owe for CT scans is: $350. You received Medicare Part B drugs on February 8, 2021. The total allowed amount is $4,017.72 and 20% of that is $803.54. The total amount you owe is: $1,153.54. You have been asked to pay the total amount of $1,153.54 for CT scans and Medicare Part B drugs. CT scans fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. Medicare Part B drugs 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 copayments for CT scans and to waive the coinsurance for Medicare Part B drugs provided from January 11, 2021, to February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of an impacted tooth (D7240) provided on April 7, 2021.
You asked the Plan to pay for the removal of an impacted tooth. You say that you made payment for tooth #16 that was denied and not covered. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 removal of an impacted tooth (D7240) provided on April 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for hemiarthroplasty (27125) provided on December 26, 2020.
You asked the Plan to pay for hemiarthroplasty. You say that this code is supported. The Plan denied your request. The Plan says there is a more appropriate code for the service performed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 27125 is hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty). We asked our coder 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 hemiarthroplasty. Our reviewer says that this code is not supported. Our reviewer found the operative report does not describe replacing one half of the hip joint with a prosthetic, therefore, this procedure cannot be confirmed as performed. The documentation describes the treatment of an intertrochanteric fracture. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hemiarthroplasty have not been met. Therefore, we decided that the Plan does not have to pay for hemiarthroplasty (27125) provided on December 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a crown (D2740), and a core buildup (D2950) provided from March 31, 2021, through April 14, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, a crown, and a core buildup. You say that the services were necessary as your previous crown had broken The Plan denied your request. The Plan says the comprehensive oral evaluation is a covered benefit, but you have exceeded the frequency limit of one every 3 Plan years. The crown and core buildup are covered benefits, but you have exceeded the frequency limit of one per tooth every 5 Plan years. 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, a crown, and a core buildup have not been met. Specifically, the record shows that you had exceeded the frequency limit for the comprehensive oral evaluation prior to this service on January 29, 2020. Additionally, the record shows that you had exceeded the frequency limit for the crown and the core build up prior to this service on January 30, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a crown (D2740), and a core buildup (D2950) provided from March 31, 2021, through April 14, 2021.