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

We decided that the Plan does not have to pay forthe bitewing x-rays and two crowns provided on August 20, 2020, and September 10, 2020.You asked the Plan to pay forthe bitewing x-rays and two crowns. You say that you should have ample coverage to cover at least half of the fee because you have a $2,000 allowance for dental coverage.The Plan denied your request. The Plan says your benefits for the bitewing x-rays had been satisfied and the frequency limitation had been exceeded. The Plan also says that these services were performed by a non-participating provider, and you are responsible for the difference between the Maximum Allowable Fee and the amount the provider bills you for the 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, you are responsible for the difference between the billed amount and allowed amount. The contract also clearly states that bitewing x-rays are limited to one procedure per calendar year. The record shows that you received bitewing x-rays on July 20, 2020, and your bitewing x-rays benefit had been exhausted. The record also shows that you did not contact the Plan prior to the date ofservice to verify benefits and provider eligibility.Therefore, we decided that the Plan does not have to pay forthe bitewing x-rays and two crowns provided on August 20, 2020, and September 10, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 27, 2020, 
through September 29, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient hospital care provided 
was medically necessary. The Plan denied your request. The Plan says that the inpatient hospital care was not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the patient meets admission criteria with fever, profound leukocytosis, edema 
with cellulitis, as well as the need for intravenous steroids. This was a medically reasonable decision to 
hospitalize the enrollee. The physician reasonably expected that the patient's necessary hospital care would 
span two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from September 27, 2020, through September 29, 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe advanced foot and ankle feature.You asked the Plan to pay forthe advanced foot and ankle feature. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says the advanced foot and ankle feature as exceeds enrollee's functional need and does not meet Medicare criteria of reasonable and necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 pay for the advanced foot and ankle feature. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that there has been a change in the physiological condition of the patient that requires a new prosthetic foot. There is no irreparable wear of the device or a part of the device. The condition of the device is not noted to repairs.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 advanced foot and ankle feature have not been met.Therefore, we decided that the Plan doesnot have to pay forthe advanced foot and ankle feature.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to issue reimbursement ofthe copaymentfor the low dose computed tomography (CT) scan (LDCT) (G0297) provided on August 14, 2020.You asked the Plan to issue reimbursement of the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says that they did not complete its review by the compliance due date; therefore, they are required to auto-forward the case file to Medicare's independent review entity.The rules say a plan must disclose to its enrollees inclear, accurate terms all cost sharing information. Your contract with the Plan says that there is no coinsurance, copayment, or deductible for the Medicare covered counseling and shared decision-making visit or for the low dose computed tomography (LDCT)scan when the services are rendered by an in-network provider.The Plan says you must pay a $77.62 copayment for the LDCT scan provided. Based on the Plan contract, however, there is no coinsurance, copayment, or deductible for the Medicare covered LDCT scan when provided by an in-network provider.The service at issue was rendered by a participating Plan provider. Therefore, we decided that the Plan has to issue reimbursement of the copaymentfor the low dose computed tomography (CT) scan (LDCT) (G0297) provided on August 14, 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 toopen the case again, we will send you a letter
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) provided on September 23, 2020.You asked the Plan to pay forthe comprehensive oral evaluation. You say that this service is necessary.The Plan denied your request. The Plan says you have exhausted this 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. The Plan covers the comprehensive oral evaluation once every three years. We looked at the file and Medicare rules. The file indicates that you last received this service in August 2020. Therefore, you have received this service within the last three years and exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral evaluation have not been met.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) provided on September 23, 2020
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on August 28, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because
these tests were ordered by the member's primary care physician. The Plan denied your request. The Plan says
that Medicare does not cover services required by a third party.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the
laboratory services is considered approved by the plan. Therefore, we decided that the Plan has to pay for the
laboratory services provided on August 28, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 27, 2020, by an OON provider.You asked the Plan to pay fora domiciliary or rest home visit and for advance care planning. You say that the provided services were reasonable and medically necessary.The Plandenied your request. The Plan says rules for payment have not been met.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 forthe medical services provided on May 27, 2020, by an OON provider
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the deductible for the ultrasound and reduce the cost-sharing from $178.60 to $25.
You asked the Plan to waive the deductible for the ultrasound. You say that the service should not be applied to the deductible. The Plan denied your request. The Plan says that the cost sharing was applied correctly.
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 enrollees must pay a $25 copayment for other Medicare-covered outpatient diagnostic procedures and tests. The Plan says you must pay a $45 copayment after you meet your $250 deductible for the ultrasound. Based on the Plan contract, however, you cannot be asked to pay more than a $25 copayment for the ultrasound. In addition, the Plan contract lists services for which the deductible applies. An ultrasound was not listed as a service for which the deductible applies. Therefore, we decided that the Plan has to waive the deductible for the ultrasound (76641) provided July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the member liability forthe periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on September 17, 2020.You asked the Plan to waive the member liability forthe dental services. You say that you have been going to this dentist for fifteenyears. You saythat you did not know that he was out of network. You also say that you have never filed a claim before.The Plan denied your request. The Plan says the provider in this case is out-of-network. The Plan says that you may be billed more by an out-of-network provider if the charge is greater than MAC.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 are responsible for all fees in excess of the allowed amount for services that you receive out-of-network.CPT CodeBilled AmountAllowed AmountPlan PaidMember LiabilityD0120$65$19$19$46D1110$111$$41$41$70D0274$74$26$26$48TOTAL:$164Therefore, we decided that the Plan does not have to waive the member liability forthe periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on September 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forservices provided outside of the United States of America and transportation ancillary provided on December 2, 2019.You asked the Plan to pay forservices provided outside of the United States of America and transportation ancillary. You say that the Plan should pay this claim.The Plan denied your request. The Plan says these procedure codes are not valid for Medicare purposes.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 Manualdefinition of code S9989is services provided outside of the United States of America (list in addition to code(s) for service(s)). The CPT Code Manual definition of code A0170 is Transportation ancillary: parking fees, tolls, other. We find that CPT code S9989 is not a valid code for Medicare purposes. S codes are unique temporary codes established by BCBSA and HIAA for private payor use. CPT code A0170 has a status code of I. They are not valid nor payable by Medicare. Medicare uses another code for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pay forservices provided outside of the United States of America and transportation ancillary provided on December 2, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the Dual-energy X-ray absorptiometry (DXA), bone 
density study (77080) provided on August 7, 2020. 
 
You asked the Plan to waive the copayment for the bone density study. You say that the scan was preventative 
and diagnostic and should not have a copayment. The Plan denied your request. The Plan says that that many 
diagnostic tests do not have a copay, but x-rays and ultrasounds are subject to a $20 copayment when provided 
in-network. 
 
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 enrollees must pay no charge when provided in-network for bone mass 
measurement.  
 
The Plan says you must pay $20 copayment for bone density study. The Plan made this decision by using the 
Outpatient Diagnostic Tests section of the EOC, which states that there is a $20 copayment for x-rays and 
ultrasounds. The service at issue is more accurately described as Bone mass measurement. The EOC shows that 
there is no charge for bone mass measurements when provided in-network. Based on the Plan contract you 
cannot be asked to pay a coinsurance, copayment, or a deductible amount for a bone density study provided in-
network. Therefore, we decided that the Plan has to waive the copayment for the Dual-energy X-ray 
absorptiometry (DXA), bone density study (77080) provided on August 7, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0481) provided on September 29, 2020. 
 
You asked the Plan to pay for the drug test. You say that you would like reconsideration because this testing 
was time sensitive and medically necessary. The Plan denied your request. The Plan says the documentation 
submitted does not include a specific reason for doing a definitive drug test. 
 
The Plan must follow Medicare rules. Medicare rules say that the clinician's rationale for the definitive UDT 
and the tests ordered must be documented in the patient's medical record. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug test have not been met. Specifically, the record does not include clinical notes from the 
ordering physician. There is no record of the rationale for the UDT documented. Therefore, we decided that the 
Plan does not have to pay for the drug test (G0481) provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2335), the crown (D2750), and the core build up (D2950) provided on September 23, 2020.
You asked the Plan to pay for the dental services. You say that you have had 2 cleanings, one of which was periodontal maintenance. You also say that you did not know that you had a dental rider available to you until October 22, 2020. The Plan denied your request. The Plan says the filling is not listed as a covered service. The Plan says that the crown is not listed as a covered service. The Plan also says that the core build up 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filling (D2335), the crown (D2750), and the core build up (D2950) provided on September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the urgent care visit provided on 
September 18, 2020. 
 
You asked the Plan to reduce the copayment for the urgent care visit. You say that you have always paid a $35 
specialty office copayment when seen for urgently needed services. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 
copayment for Medicare-covered urgently needed care visits.  
 
You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently needed services benefit category. The record shows you were seen at an urgent care center. 
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 reduce the copayment for the urgent care visit provided on September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until September 24, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the urgent care services provided on August 30, 
2020. 
 
You asked the Plan to waive the copay for the services provided. The Plan denied your request. The Plan says 
the claim was processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copay for each visit for urgently needed services.  
 
You have been asked to pay a $40 copay for the services provided. The services fall within the urgently needed 
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 copay for the urgent care services 
provided on August 30, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forpsychiatric services provided on February 20, 2019.You asked the Plan to pay forthe psychiatric services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the claim was untimely.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 psychiatric services was not filed until September 3, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forpsychiatric services provided on February 20, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe diagnostic examination of voice box using flexible endoscope (31575).You asked the Plan to waive the copayment forthe diagnostic examination of voice box using flexible endoscope. You say that you would like this copayment waived.The Plan denied your request. The Plan says the copayment has processed correctly in this case.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 $45 copayment for specialist services. You have been asked to pay a $45 copayment for the diagnostic examination of voice box using flexible endoscope. The service providedfalls within the specialist 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 forthe diagnostic examination of voice box using flexible endoscope (31575).