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

We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents and comprehensive oral evaluation provided on January 20, 2021.

You asked the Plan to pay for the localized delivery of antimicrobial agents and comprehensive oral evaluation. You say that you believe these services should be covered. The Plan denied your request. The Plan says localized delivery of antimicrobial agents is not a covered service under your plan. The Plan also says that the comprehensive oral evaluation exceeds the frequency limitations under your 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, localized delivery of antimicrobial agents is not among those covered under this benefit. The contract says that comprehensive oral exam is limited to once every 36 months. The record shows that you received a comprehensive oral evaluation on February 24, 2020 and your comprehensive oral exam benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the localized delivery of antimicrobial agents and comprehensive oral evaluation provided on January 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on December 1, 2020.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment 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 $295 copayment for outpatient surgical services not provided in an ambulatory surgical center.

Review of the file shows that you received outpatient surgical services at an outpatient hospital facility on December 1, 2020. You have been asked to pay a $295 copayment for these services. These services fall within the outpatient surgical services not provided in an ambulatory surgical center 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 outpatient surgical services rendered on December 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided October 30, 2020.

You asked the Plan to pay for the lab services. You say that the lab test was medically necessary. The Plan denied your request. The Plan says this service is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. 

We looked at the file and Medicare rules. This type of test is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided October 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan provided on September 8, 2020.

You asked the Plan to waive the copayment for CT scan. You say that you are appealing this charge. 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 $150 copayment for CT scan. 

You have been asked to pay the allowed amount of $126.28, which is less than the $150 copayment for CT scan. CT scan 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 a Computed Tomography (CT) scan provided on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood bank physician services rendered on September 18, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 86077 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the blood bank physician services rendered on September 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0425 and A0426) provided on
August 8, 2020.

You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because this
diagnosis code billed is appropriate. The Plan denied your request. The Plan says The secondary diagnosis code
(R79.89) that was submitted is not permitted per Centers for Medicare & Medicaid Services (CMS).

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. A
secondary diagnosis, from ICD-10 Code Group 3, must be reported.

We find that CPT code A0425 and A0426 is not supported in the record. Specifically, this claim was not
submitted with one of the required secondary diagnosis codes. Based on this information, we decided that
Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan
does not have to pay for the ambulance services (A0425 and A0426) provided on August 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), teeth cleaning (D1110), and a core buildup (D2950) provided on December 1, 2020.

You asked the Plan to pay an additional amount for a periodic oral evaluation, teeth cleaning, and a core buildup. You say that you would like the Plan to pay an additional amount towards the services and you do not want to see another dental provider. The Plan denied your request. The Plan says the claims for these services were processed correctly with the applicable out-of-network allowable amount paid.

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 covers out-of-network dental services up to a maximum allowed amount per service. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, teeth cleaning, and a core buildup have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Any amount beyond the allowed amount is your contractual responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), teeth cleaning (D1110), and a core buildup (D2950) provided on December 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an epidural injection (62321) provided December 3, 2020.

You asked the Plan to waive the copayment for the injection. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for outpatient surgical services. 

You have been asked to pay a $350 copayment for the injection. The injection falls within the outpatient surgical services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an epidural injection (62321) provided December 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81286, 81404, 81407, 81408, 81479) provided October 2, 2020.

You asked the Plan to pay for the lab services. You say that the testing was medically necessary. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

We looked at the file and Medicare rules. This cardiovascular risk assessment is not a covered test. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81286, 81404, 81407, 81408, 81479) provided October 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry services rendered on November 11, 2020.

You asked the Plan to waive the copayment for these services. You say that you did not approve of the services. The Plan denied your request. The Plan says the copayment 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 $35 copayment per visit for Medicare-covered podiatry services.

Review of the file shows that you had podiatry services on November 11, 2020. You have been asked to pay a $35 copayment for these services. These services fall within the Medicare-covered podiatry services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the podiatry services rendered on November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0140, D7140, D0220).

You asked the Plan to pay for the dental services (D0140, D7140, D0220). You say that you had an infected tooth that required extraction. The Plan denied your request. The Plan says the requested services are not covered under your supplemental 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. The plan only covers those services listed in your Evidence of Coverage. Therefore, we decided that the Plan does not have to pay for the dental services (D0140, D7140, D0220).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered from September 7, 2020 to September 9, 2020.

You asked the Plan to waive the copayment for these services. You say that you should have been discharged sooner. The Plan denied your request. The Plan says the copayment 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 $395 copayment per day for days 1-4 for inpatient hospital care.

Review of the file shows that you received two days of inpatient hospital care from September 7, 2020 to September 9, 2020. You were not assessed a copayment for your date of discharge on September 9, 2020. You have been asked to pay a $395 copayment per day for these services, for a total of $790. These services fall within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered from September 7, 2020 to September 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (CPT 99231) provided on September 30, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says that payment for this service is included in the anesthesia payment.

The Plan must follow Medicare rules. Medicare rules say that starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient may be placed safely under postoperative care. We looked at the file and Medicare rules. In this case, the time reported under the anesthesia procedure code ends when the enrollee is sent to postoperative care. Any services provided after the enrollee is sent to postoperative care are not considered part of the anesthesia service. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for the services (CPT 99231) provided on September 30, 2020.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ambulance transports provided on August 12, 2020.

You asked the Plan to waive the coinsurance for the ambulance transports. You say that she should not be responsible for the provider's decision to send her to the emergency room.The Plan denied your request. The Plan says the coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% of the cost for each Medicare-covered one-way trip.

The enrollee has been asked to pay a total of $131.02 for the ambulance transports. 

The ambulance transports fall 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 coinsurance forthe ambulance transports provided on August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation (D7953) provided on November 9, 2020.

You asked the Plan to pay for the bone replacement graft. You say that your provider was in-network and these services should be covered as such. The Plan denied your request. The Plan says they will pay for the surgical placement of implant bodies (D6010) and the extraction (D7210). However, the bone replacement graft is not covered by Medicare or by the Plan's supplemental dental benefit, regardless of who provides the 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 a bone replacement graft for ridge preservation (D7953) provided on November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on January 4, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you had breathing problems and had a routine check-up and was then charged a $40 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 $40 copayment for each covered visit or consultation in an outpatient location with a specialist. You have been asked to pay a $40 copayment for the specialist office visit. The specialist 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 the specialist office visit provided on January 4, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on July 2, 2020.

You asked the Plan to pay for the hospital discharge day management. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management provided on July 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (73110) provided August 18, 2020.

You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says original Medicare is liable for payment.

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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for an x-ray (73110) provided August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam rendered on July 10, 2020.

You asked the Plan to waive the copayment for these services. You say that you paid the copayment in cash. The Plan denied your request. The Plan says the copayment 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 $35 copayment for each visit to a specialist, such as an ophthalmologist or optometrist, for Medicare-covered benefits.

Review of the file shows that you had an eye exam on July 10, 2020. You have been asked to pay a $35 copayment for these services. These services fall within the visit to a specialist, such as an ophthalmologist or optometrist, for Medicare-covered benefits 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.

The file shows that the Plan wrote off the copayment for the eye exam on June 24, 2020. You do not owe a copayment for this date of service. The copayment on July 10, 2020 has not been paid. The coinsurance of $2.57 applied for the exam on January 31, 2020 has been waived by the Plan. The amount you are being asked to pay is your contractual copayment for the eye exam on July 10, 2020.

Therefore, we decided that the Plan does not have to waive the copayment for the eye exam rendered on July 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder test provided on November 18, 2020.

You asked the Plan to pay for the CxBladder test. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that LCD L35396 provides a list of covered molecular bladder tests. 

We looked at the file and Medicare rules. The requested CxBladder test is not listed as a covered test per LCD L35396. Based on this information, we decided that Medicare rules for coverage of the CxBladder test have not been met.Therefore, we decided that the Plan does not have to pay for the CxBladder test provided on November 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on March 24, 2020.

You asked the Plan to waive the copayment for the ambulance transport. You say that the ambulance services should be covered in full. The Plan denied your request. The Plan says the copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay $225 for Medicare-covered ambulance services per day. 

The enrollee has been asked to pay a $225 copayment for the ambulance transport. The ambulance transport 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 transport provided on March 24, 2020.