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

We decided that the Plan does not have to pre-approve the removals of residual tooth roots (D7250) for tooth #'s 20, 21, 29, 30, 31, and 32.
You asked the Plan to pre-approve the removals of residual tooth roots. You say that these teeth need to be extracted in order to treat and prevent further infection. The Plan denied your request. The Plan says this way of pulling out the enrollee's teeth is not medically necessary.
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 removals of residual tooth roots when the services are medically necessary and reasonable. 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 removals of residual tooth roots. Our reviewer says that the removals of residual tooth roots (D7250) do not meet the criteria for coverage via procedure code D7250 (cutting procedure). Our physician reviewer found the dental record and radiographs indicate that these residual roots #'s 20, 21, 29, 30, 31, and 32 appear to be exposed, allowing removal via elevation and/or forceps (D7140). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the removals of residual tooth roots have not been met. Therefore, we decided that the Plan does not have to pre-approve the removals of residual tooth roots (D7250) for tooth #'s 20, 21, 29, 30, 31, and 32.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from December 26, 2020, through December 28, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you did not have a choice due to COVID and you shouldn't have to pay this bill. 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). Your contract with the Plan clearly says that you must pay a $300 copayment per day for days 1-6 for in-network, Medicare-covered hospital stays. You have been asked to pay a $300 copayment for the inpatient stay. The inpatient stay falls 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 stay provided from December 26, 2020, through December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 18, 2020.

You asked the Plan to waive the copayment for the office visit. You say that only the $275 charge is valid. You say that the $35 for the office visit should not be part of this bill. 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). Your contract with the Plan clearly says that you must pay a $35 copayment for each specialist visit. 

You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show you received services with a specialist during the office visit. 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 office visit provided on December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) received July 7, 2020.
You asked the Plan to pay for the determination of refractive state. You say that the service should be covered because it was received from a network provider. The Plan denied your request. The Plan says this is a covered supplemental benefit only when obtained from a preferred (in-network) provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when received from an in-network provider. We looked at the file and the Plan's rules. The Plan covers some routine vision care services when performed by a preferred provider. The provider in this case was determined to not participate in the plan's vision care network. Based on this information, we decided that the Plan's rules for coverage of the determination of refractive state have not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) received July 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electric neuromuscular stimulator provided on August 10,
2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the
reasonableness of the provided equipment has not been established.

The Plan must follow Medicare rules. Medicare rules say if a supplier knowingly contacts an individual in
violation of this prohibition, no payment may be made for any item subsequently furnished to the individual by
the supplier.

We looked at the file, and Medicare rules. In this case, it appears that the enrollee was contacted via an
unsolicited phone call. As such, no payment may be made for this item. Therefore, we decided that the Plan
does not have to pay for the electric neuromuscular stimulator provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure provided on March 12, 2020.
You asked the Plan to pay for the therapeutic procedure. You say that you need therapeutic exercise to benefit your overall health. The Plan denied your request. The Plan says you received a non-covered chiropractic service that is explicitly excluded.
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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure provided on March 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture and reline of complete mandibular denture provided on August 4, 2020, and August 11, 2020.
You asked the Plan to pay for the complete maxillary denture and reline of complete mandibular denture. You say that this procedure was delayed due to the COVID-19 pandemic. You also say that this procedure was approved prior to the pandemic, and you do not feel that you should be held responsible. The Plan denied your request. The Plan says dentures were not a covered service under the Plan at the time the services were rendered. The Plan also says that there is no prior authorization on file for dentures for the 2020 plan year.
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 complete maxillary denture and reline of complete mandibular denture provided on August 4, 2020, and August 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the temporary replacement equipment provided on January 14, 2021.

You asked the Plan to waive the coinsurance for the temporary replacement equipment. You say that you would like to appeal because you are on a fixed income. 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 20% coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies. 

You have been asked to pay $14.00 which is 20% of the allowed amount for the temporary replacement equipment. The allowed amount is $70. ($70 x 20% = $14). The temporary replacement equipment falls within the "Durable medical equipment (DME) and related 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 coinsurance for the temporary replacement equipment provided on January 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on October 27, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there was no order for these services.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing services provided to the enrollee on October 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 crowns (D6740) and the pontic (D6245).
You asked the Plan to pay for the 2 crowns and the pontic. You say that you did not know the requested services would not be covered. 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 requested services are not listed under the plan's covered supplemental benefit. Therefore, we decided that the Plan does not have to pay for the 2 crowns (D6740) and the pontic (D6245).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 5, 2020.
You asked the Plan to pay for the ambulance services. You say that you did not know you would have to pay for this service. 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 5, 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 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), the cleaning (D1110), and the bitewing x-rays (D0274) provided on December 7, 2020.
You asked the Plan to pay for the dental services. You say that you do not have the funds to pay for these services. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000 for dental services. The Plan says that the benefit has been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, the annual maximum benefit has been exhausted. The record shows that the Plan paid $96 for dental services that you received on May 27, 2020, and $904 for dental services that you received on June 18, 2020. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), the cleaning (D1110), and the bitewing x-rays (D0274) provided on December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on December 30, 2020.
You asked the Plan to pay for the dental service. You say that the services should be covered. The Plan denied your request. The Plan says there is an annual allowance of $1,000 for covered dental services. The Plan says that the allowance has been exhausted.
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 annual allowance has been exhausted.
Date of Service
Plan Paid
1/28/2020
$676
2/17/2020
$94
2/27/2020
$89
12/30/2020
$141
TOTAL:
$1,000
Additionally, the Evidence of Coverage clearly states that you are responsible for any amount over and above the allowance amount. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography services provided on October 21, 2019.
You asked the Plan to pay for the services provided. You say that the bill should be covered by the Plan. The Plan denied your request. The Plan says the claim 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 $10 copay for basic radiological services in a specialist office. You have been asked to pay a $10 copay for the services provided. However, the records show that the provider has written off the copay on their end. The services fall within the outpatient diagnostic tests 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 further pay for the echocardiography services provided on October 21, 2019.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that the enrollee's high functional level needs therapy on an intensive level 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on December 16, 2020.
You asked the Plan to pay for the periodontal maintenance. You say that you went to this appointment for a regular cleaning and do not feel that you should be held responsible. The Plan denied your request. The Plan says this service exceeds the frequency limitation in 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, periodontal maintenance (D4910) is limited to three procedures per plan year. The record shows that you received periodontal maintenance (D4910) services on January 15, 2020, July 15, 2020, and October 29, 2020, and your periodontal maintenance (D4910) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on December 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive cardiovascular gene panel (81286, 81404, 81405, 81406, 81407, 81408, 81479) provided on September 9, 2020.
You asked the Plan to pay for a comprehensive cardiovascular gene panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive cardiovascular gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive cardiovascular gene panel (81286, 81404, 81405, 81406, 81407, 81408, 81479) provided on September 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on July 28, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you were not advised of the charge pre-transfer. You say that the charge was part of the hospital bill and you do not feel you owe this bill. 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). Your contract with the Plan clearly says that you must pay a $225 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 ambulance transport provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 25, 2021 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that the enrollee did not inform you that their insurance had changed. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 an office visit provided on January 25, 2021 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the enrollee on August 13, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0482 (1 Unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that HCPCS code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services (HCPCS G0482) provided to the enrollee on August 13, 2020.