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

We decided that the Plan does not have to pay for the limited oral evaluation (D0140 and periapical x-ray (D0230) provided on June 15, 2021, provided by the out of network dentist.
You asked the Plan to pay for the dental services. You say that you feel these services should be covered. The Plan denied your request. The Plan says the limited oral evaluation is not listed as a covered service. The Plan says that periapical x-ray is not listed as a covered service either. The Plan also says the provider was advised by a plan representative which codes, specifically, were 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 limited oral evaluation and
periapical x-ray are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140 and periapical x-ray (D0230) provided on June 15, 2021, provided by the out of network dentist
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Botulinum toxin injection you received on March 17, 2021.

You asked the Plan to waive the coinsurance for the Botulinum toxin injection. You say that you could not afford the $250 copayment for these injections, and you advised your doctor of that. You stated that he advised you would be given a sample of the Botulinum toxin so that your only copayment would be the office visit copayment. You stated that you should not have to pay the coinsurance for this drug since the doctor told you it would be free. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B drugs. 

You have been asked to pay 20% coinsurance for the Botulinum toxin injection. the Botulinum toxin injection falls within the Medicare Part B drugs benefit category. The medical records from this visit show that you received a total of 600 units of this drug and only 100 units were from a sample. You were charged coinsurance on the remaining 500 units that were not part of the sample.

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 Botulinum toxin injection you received on March 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an abdominal aorta ultrasound provided on April 29, 2021.

You asked the Plan to waive the copayment for an abdominal aorta ultrasound. You say that this should be considered an AAA screening because you fit the criteria and you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for ultrasounds. 

The record shows that you received an abdominal aorta ultrasound on April 29, 2021. Unfortunately you do not meet the criteria for an AAA screening. Therefore, you are responsible to pay the allowed amount of $83.18, which is less than the $125 copayment. 

You have been asked to pay $83.18 for an abdominal aorta ultrasound. An abdominal aorta ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an abdominal aorta ultrasound provided on April 29, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on
April 16, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that you were told to go to the ER
because your blood pressure was too low. The Plan denied your request. The Plan says you were charged this
copayment 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 $90
copayment for emergency care.

You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason
for the ER 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 emergency room (ER) visit
you had on April 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on April 28, 2021.

You asked the Plan to pay for the ambulance service. You say that you fainted on a bicycle ride. You say that someone called the ambulance for you. You say that you had recovered by the time the ambulance arrived. You say that you never took the ambulance to the hospital. You also say that you feel this should be covered. The Plan denied your request. The Plan says ambulance benefit is a transportation benefit. The Plan also says without a transport, there is no payable service.

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 April 28, 2021. 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 response and treatment, no transport, (A0998) provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning (D1110) provided on June 1, 2021.

You asked the Plan to pay for the dental service. You say that you went to an in-network dentist and were
advised you needed all of this work done. You say that as a result you went back to the out of network dentist
to get your teeth cleaned. You also say that this service should be covered. The Plan denied your request. The
Plan says the provider in this case is out of network. The Plan also says dental services you receive out of
network 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 and the cleaning is listed as covered,
dental services received out of network are not among those covered under this benefit. Therefore, we decided
that the Plan does not have to pay for the cleaning (D1110) provided on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483, 80307) provided on August 28, 2020.

You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with an incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483, 80307) provided on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and unspecified preventive service (D1999) provided on April 12, 2021.

You asked the Plan to pay for the dental services. You say that you asked a plan representative if the dental office was in network. You say that the claim was denied. You say that you were advised by a plan representative that you would be covered. You also say that you would have changed dentists had you known. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services received out of network 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 dental services received out of network are not among those covered under this benefit. Additionally, the record shows that you were advised by a plan representative the dental office was not found in the system and therefore a specific dentist could not be confirmed as in network.

Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and unspecified preventive service (D1999) provided on April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 1, 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 were not billed correctly.

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 laboratory services rendered on September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction provided on June 18, 2021.

You asked the Plan to pay for the refraction. You say that you were trying to get another pair of glasses and
was told you needed a new prescription. You say that you are appealing the decision that the vision service is
not covered. The Plan denied your request. The Plan says the claim processed correctly.

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 a refraction when provided with a routine eye exam from a network provider.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the medical eye exam and refraction have not been met. Specifically, this provider is not a network
provider for your routine vision benefits. Therefore, we decided that the Plan does not have to pay for the
refraction provided on June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator rental (K0606) rendered by the out-of-network (OON) provider on February 25, 2021.

You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the item was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at issue.

We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator rental (K0606) rendered by the out-of-network (OON) provider on February 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 16, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records do not show that the specimen was collected in a laboratory setting. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on September 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an air-fluidized bed and a free-standing trapeze for the
enrollee.

You asked the Plan to pre-approve the items. You say that the criteria were not met. The Plan denied your
request. The Plan says this is medically 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 pre-approve the items. Our reviewer says that the
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation does not reveal that the enrollee has not had progression towards wound healing. The
documentation does not reveal that the enrollee has home health care to assist with wound care as the enrollee
goes to a weekly wound clinic. There is no evidence that in the absence of an air-fluidized bed, the enrollee
would require institutionalization.

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 items have not been met. Therefore, we decided that the Plan does not have
to pre-approve an air-fluidized bed and a free-standing trapeze for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided on April 8, 2021.

You asked the Plan to pay for ConfirmMDx testing. You say that this is a covered service. The Plan denied
your request. The Plan says this was not indicated for the enrollee.

The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is covered for males aged 40 to 85
years old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being
considered for a repeat biopsy due to persistent or elevated cancer-risk factors.

We looked at the file and Medicare rules. The records do not show that the enrollee was being considered for a
second biopsy. Based on this information, we decided that Medicare rules for coverage of ConfirmMDx testing
have not been met. Therefore, we decided that the Plan does not have to pay for ConfirmMDx testing (81551)
provided on April 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray of the hand you had on February 26, 2019.

You asked the Plan to waive the copayment for the x-ray. You say that you don't know what this bill is for because you believed that all of your claims had been paid in full. The Plan denied your request. The Plan says you were charged this copayment 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 $50 copayment for x-rays in a provider's office.

You have been asked to pay a $50 copayment for the x-ray. 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 x-ray of the hand you had on February 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7140), mandibular partial denture (D5214), and fixed partial denture sectioning (D9120) provided on May 20, 2021, and June 3, 2021.

You asked the Plan to pay for the extractions, mandibular partial denture, and fixed partial denture sectioning. You say that these services were essential to recovering your hearing and general health. You also say that you would like to be reimbursed for these services. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. The Plan also says that you did not purchase the optional platinum dental rider.

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 extractions (D7140), mandibular partial denture (D5214), and fixed partial denture sectioning (D9120) provided on May 20, 2021, and June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 9, 2021.

You asked the Plan to pay for the dental service. You say that your plan allows for $1,000 per year. You also say that you do not understand why this service is not covered. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has been exceeded.

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 service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on April 27, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision of a benign lesion up to 1.25 centimeters (D7410) provided on June 30, 2021.

You asked the Plan to pay for the dental service. You say that your doctor advised they could not remove the lesion. You say that you decided to wait to have it removed by your dentist until you received a coronavirus vaccine. You say that you keep biting the lesion. You say that the lesion continues to get bigger and bigger. You also say that you would like this service to be covered. The Plan denied your request. The Plan says the excision of a benign lesion 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 excision of a benign lesion is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the excision of a benign lesion up to 1.25 centimeters (D7410) provided on June 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital stays provided from May
2, 2021, to May 10, 2021, and from May 28, 2021, to June 4, 2021.

You asked the Plan to waive the copayment for two inpatient hospital stays. You say that you are willing to pay
for the first week of hospital care. You also say that you believe the rest of the hospital stay should be covered.
The Plan denied your request. The Plan says the copayment applied was 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $180 copayment per day, for days 1 to 7, for inpatient care. The enrollee's contract with the Plan
also clearly says that enrollees must pay a $0 copayment per day, for days 8 to 90, for inpatient care.
The enrollee has been asked to pay $1,260 for an inpatient hospital stay from May 2, 2021, to May 10, 2021
($180 per day x 7 days). The enrollee has also been asked to pay $1,000 for the first seven (7) days of an
inpatient hospital stay from May 28, 2021, to June 4, 2021, which is less than their copayment amount. 

The enrollee reached their in-network out-of-pocket maximum during this inpatient stay. An inpatient hospital stay
falls within the Inpatient Hospital Care 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 inpatient hospital stays provided from May 2, 2021, to May 10, 2021, and from May 28, 2021,
to June 4, 2021.