Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physician services provided from November 3, 2020, to December 31, 2020.
You asked the Plan to waive the copayments for the physician services. You say that you thought copayments were waived due to COVID-19. The Plan denied your request. The Plan says you were charged the copayments 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 Physician Services. You have been asked to pay a $10 copayment for each of the physician services. The physician services fall within the Physician 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 copayments for the physician services provided from November 3, 2020, to December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the member liability for the comprehensive oral evaluation
(D0150) and the complete series x-ray (D0210), and to pay for the scaling in presence of generalized moderate
or severe gingival inflammation (D4346) provided from January 25, 2021, to January 27, 2021.
You asked the Plan to waive the member liability for the oral evaluation and x-rays and pay for the scaling for
gingival inflammation. You say that you sent a plan materials book when you first signed up that advised you
to select a dentist in the book. You say that it also stated you would get 1 free x-ray and cleaning. You say that
you should not have been billed for these services. You also say that you did just as you were told, and the
services should be covered.
The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that out
of network providers may bill you for any amount greater than the payment made by the plan to the provider or
any services not covered by the plan. The Plan also says that scaling in presence of generalized moderate or
severe gingival inflammation 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 and the oral evaluation and cleaning are
listed as covered, dental services performed out of network may cost more. Member liability is a contractual
obligation you agreed to when you enrolled in the Plan's dental coverage. Additionally, the scaling in presence
of generalized moderate or severe gingival inflammation is not among those covered under this benefit.
Therefore, we decided that the Plan does not have to waive the member liability for the comprehensive oral
evaluation (D0150) and the complete series x-ray (D0210), and to pay for the scaling in presence of
generalized moderate or severe gingival inflammation (D4346) provided from January 25, 2021, to January 27,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital clinic visits provided on January 14, 2020 and June 30, 2020.

You asked the Plan to waive the copayment for clinic visits. You say that the copayment for an office visit is usually $40. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.

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 $200 copayment for each outpatient hospital clinic visit. For January 21, 2020 you have been asked to pay the allowed amount of $119.86, which is less than the $200 copayment for an outpatient hospital clinic visit. For June 30, 2020 you have been asked to pay the allowed amount of $117.04, which is also less than the $200 copayment for an outpatient hospital clinic visit. Your total copayment responsibility is therefore $236.90. 

You have been asked to pay less than $200 copayment for each clinic visit. Clinic visits fall 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 outpatient hospital clinic visits provided on January 14, 2020 and June 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CGM provided on October 15, 2020.
You asked the Plan to pay for the CGM. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says there is no documentation the enrollee is managed with insulin injections. The Plan also says that it is noted for the enrollee to check their blood sugars 1 to 2 times per day.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pay for the CGM provided on October 15, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation and management service provided on September 10, 2020.
You asked the Plan to pay for the physician service. You say that the service was 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 telephone evaluation and management service provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 16, 2020 by an out of network provider.
You asked the Plan to pay for the physician services. You say that the doctor was unaware a prior authorization was needed. The Plan denied your request. The Plan says you did not request prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 physician services provided on November 16, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral periapical x-rays (D0210) provided on February 2, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral periapical x-rays. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services exceed the maximum allowed per period.
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, comprehensive oral evaluation (D0150) and complete series of intraoral periapical x-rays (D0210) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral periapical x-rays (D0210) on November 21, 2019, and your comprehensive oral evaluation (D0150) and complete series of intraoral periapical x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral periapical x-rays (D0210) provided on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a psychotherapy visit provided on January 4, 2021.
You asked the Plan to waive the copayment for office visit. You say that the Plan did not notify you that you were still eligible for telehealth therapy, so this copayment should be waived. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 copayment for each in-person outpatient mental health visit. You have been asked to pay $20 copayment for office visit. Office visit falls within the Outpatient Mental Health 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 a psychotherapy visit provided on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two crowns and two core buildups, including any pins when required provided on February 10, 2021.
You asked the Plan to pay for the crowns and core buildups. You say that last year you were advised that this provider was in-network. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two crowns and two core buildups, including any pins when required provided on February 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 31, 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 October 31, 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 October 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 7, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on August 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 30, 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 November 30, 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 November 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on January 13, 2021.
You asked the Plan to waive the copayment for the MRI. You say that your coverage listed online shows an MRI is listed as a $0 copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $275 copayment for advanced imaging services at an in-network outpatient hospital.
You have been asked to pay a $275 copayment for the MRI. The 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 the MRI provided on January 13, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 13, 2020, to September 4, 2020.
You asked the Plan to pay for the SNF care provided from August 13, 2020, to September 4, 2020. You say that the services rendered are coverable under the Medicare Act. The Plan denied your request. The Plan says there were no daily skilled services provided to the enrollee on the dates of service in this case.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care provided from August 13, 2020, to September 4, 2020 have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 13, 2020, to September 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found you were admitted with acute on chronic hypoxic and hypercapnic respiratory failure
due to pneumonia. You are considered clinically unstable as you desaturate, have a worsening chest X-ray and
are receiving diuretic therapy for volume overload. You continue to receive acute care services and they have
not been denied. The record does not indicate that you require acute care services that you are not currently
receiving that would be available at the LTACH facility. The elements of the coverage criteria are not satisfied.
The requested service cannot be recommended at this time.

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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the ambulance transportation services (A0427, A0425) provided on January 5, 2021.

You asked the Plan to waive the co-payment for the ambulance transportation. You say that you cannot afford this bill. The Plan denied your request. The Plan says this co-payment was applied correctly according to your benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 co-payment or a $440 co-payment for ambulance services, depending on your county of residence. The co-payment that applies to the county in which you reside is $295.

You have been asked to pay a $295 co-payment for the ambulance transportation. 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 co-payment for the ambulance transportation services (A0427, A0425) provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 14, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid.
The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care
physician.
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 physician services provided on December 14, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to the in network rate for the comprehensive oral evaluation (D0150), the complete series x-ray (D0210), the unspecified preventive service (D1999), the periodontal maintenance (D4910), the fluoride varnish application (D1206), and the gingival irrigation (D4921) provided on January 11, 2020.
You asked the Plan to the in network rate for the gingival irrigation. You say that a plan representative advised that this office was in network. You say that you went along and made an appointment. You also say that there was no way to know if the dentist you saw at the office was in network or not. The Plan denied your request. The Plan says gingival irrigation 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to the in network rate for the comprehensive oral evaluation (D0150), the complete series x-ray (D0210), the unspecified preventive service (D1999), the periodontal maintenance (D4910), the fluoride varnish application (D1206), and the gingival irrigation (D4921) provided on January 11, 2020.