Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) and ground mileage (A0425) provided July 5, 2021.  You asked the Plan to waive the copayment for the emergency ambulance service. You say that the cost of the service is excessive. The Plan denied your request. The Plan says the copayment has been 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 $260 copayment for each Medicare-covered one-way trip via ground ambulance.  You have been asked to pay a $260 copayment for the emergency ambulance service. The emergency ambulance service 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 service, basic life support, emergency transport (A0429) and ground mileage (A0425) provided July 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve gloves (A4927).  You asked the Plan to pre-approve gloves. You say that the gloves are medically necessary. The Plan denied your request. The Plan says this item is disposable and is non-covered as it does not meet the definition of durable medical equipment.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. The item is disposable and does not meet Medicare definition of Durable Medical Equipment. Therefore, we decided that the Plan does not have to pre-approve gloves (A4927).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on May 18, 2021.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a covered screening test.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided October 5, 2021.  You asked the Plan to pay for the panoramic x-ray. You say that you were not aware that the panoramic x-ray and complete series of x-rays were subject to the same frequency limit. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers a panoramic x-ray or complete series of x-rays once every five years.   We looked at the file and Medicare rules. The Plan provided documentation showing that a complete series of x-rays was previously covered on December 22, 2020. Based on this information, we decided that the Plan's frequency limit for coverage of the panoramic x-ray has been exceeded. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for diagnostic casts (D0470), and gingival irrigation (D4921) provided by a participating provider September 2, 2021.  You asked the Plan to pay for diagnostic casts and gingival irrigation. You say that you are refusing to pay for this. You say that the Plan should pay for this. The Plan denied your request. The Plan says the dental services that were provided are not covered benefits.  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 diagnostic casts (D0470), and gingival irrigation (D4921) provided by a participating provider on September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on August 31, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.   We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on August 31, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for urgently needed services provided on September 12, 2021.  

You asked the Plan to waive the copayment for urgently needed services. You say that this was a follow-up visit and you believe you should not owe a copayment. 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 $55 copayment for urgently needed services.     

You have been asked to pay a $55 copayment for urgently needed services. Urgently needed 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 copayment for urgently needed services provided on September 12, 2021.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Epifix, per square centimeter (CPT code Q4186) and Epicord, per square centimeter (CPT code Q4187), for the enrollee.  You asked the Plan to pre-approve the items. You say that the enrollee is a diabetic and has a bone infection in their right foot due to a wound that was not healed. You state the enrollee is currently taking antibiotics and receiving wound care, which has been ongoing for two (2) to three (3) months. You state bypass surgery was done to help heal the wound and there has only been minor improvements. The Plan denied your request. The Plan says a review of the current medical literature has determined that the requested service is not medically necessary for your clinical condition because the enrollee's wound is showing clear evidence of healing with the current treatment.  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/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the Medicare guidelines state that for a service to be covered under Medicare, the service shall be reasonable and necessary. A review of the current medical literature has determined that the requested service is not medically necessary for the enrollee's clinical condition because their wound is showing clear evidence of healing with the current treatment. The items/services at issue in this case are not medically reasonable or necessary.  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 Epifix, per square centimeter (CPT code Q4186) and Epicord, per square centimeter (CPT code Q4187), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (88112, 88121, 88305) rendered by the out-of-network (OON) provider on September 21, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (88112, 88121, 88305) rendered by the out-of-network (OON) provider on September 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for incontinence supplies provided from April 27, 2021, through September 24, 2021.  You asked the Plan to pay for incontinence supplies. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies provided from April 27, 2021, through September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the immediate denture - maxillary (D5130) and immediate denture - mandibular (D5140) provided October 5, 2021.  You asked the Plan to pay for the immediate upper and lower denture. You say that you cannot afford the cost of the dentures. The Plan denied your request. The Plan says dentures are not covered under your 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, 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 immediate denture - maxillary (D5130) and immediate denture - mandibular (D5140) provided October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99212) rendered by the out-of-network (OON) provider on September 21, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99212) rendered by the out-of-network (OON) provider on  September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewing x-rays (D0274) and prophylaxis (D1110) provided on September 1, 2021.  You asked the Plan to pay for the bitewing x-rays and prophylaxis. You say that it is the provider's responsibility to know what is covered under your plan, and what procedures should be performed either on a regular basis or a calendar year. You also say that the doctor was in the wrong to perform this bitewing x-ray 6 months before it would have been due and covered. The Plan denied your request. The Plan says your benefits for these services have been satisfied and the frequency limitations have 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, bitewing x-rays are limited to one set per calendar year. The record shows that you received bitewing x-rays (D0274) on January 27, 2021 and your bitewing x-rays benefit has been exhausted. The contract also says that you are limited to two prophylaxes per calendar year. The record shows that you received prophylaxes (D1110) on January 27, 2021, and May 12, 2021 and your prophylaxis benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) and prophylaxis (D1110) provided on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 23, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like to be refunded the $120 you paid for the quarter in advance because your insurance is not paying for services you need. You also say that you would like to be reimbursed the $55 for the service that was denied. 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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on January 26, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on August 16, 2021.  You asked the Plan to pay for the comprehensive oral evaluation. You say that you feel you should be refunded for this service. The Plan denied your request. The Plan says you have exceeded the frequency limits set in the subscriber agreement.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on March 3, 2020 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on August 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on August 10, 2021, to August 15, 2021.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you have never had to pay this much for a hospital stay before. The Plan denied your request. The Plan says the correct copayment has been 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 $225 copayment per day for days 1-7. There is a $0 copayment for additional days for inpatient hospital care/in-network.   You have been asked to pay a $225 copayment per day for days 1-5 for an inpatient hospital stay. The total amount you are being asked to pay is $1,125 ($225 x 5 days = $1,125). The correct copayment has been applied to the inpatient hospital stay that was provided. An inpatient hospital stay falls within the inpatient hospital care/in-network 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 inpatient hospital stay provided by a participating provider on August 10, 2021, to August 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodic oral evaluations (D0120), bitewing x-rays (D0274), and prophylaxes (D1110) provided on March 30, 2021, and October 6, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the periodic oral evaluations, bitewing x-rays, and prophylaxes. You say that this OON treating provider has been your family provider, and you feel you should not have to see an unfamiliar person for such intimate care. You also say that you would like at least a portion of these services to be covered. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits.  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 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluations (D0120), bitewing x-rays (D0274), and prophylaxes (D1110) provided on March 30, 2021, and October 6, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a podiatrist visit provided on October 7, 2021.  You asked the Plan to waive the copayment for the podiatrist visit. You say that you feel that the provider did nothing and was disrespectful. 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 $45 copayment for each podiatry visit.   You have been asked to pay $40, which is less than the $45 copayment for the podiatrist visit. The podiatrist visit falls within the 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 a podiatrist visit provided on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (99213) provided on September 23, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not separately payable.  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 payment for CPT code 99213 is not supported in the medical record. Specifically, the records show that this service was provided on the same day as a global surgery procedure with a global period of 000. This visit is not separately payable. 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 the services (99213) provided on September 23, 2021.