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

 We decided that the Plan does not have to pay an additional amount for the limited oral evaluation (D0140), cone beam computed tomography (CT) (D0364), and root canal (D3320) provided on November 12, 2021.  You asked the Plan to pay an additional amount for the dental services. You say that you were approved to receive a root canal out of network. You say that you were advised the root canal would be covered at 50%. You say that you paid $1,085. You also say that the Plan only paid $277.40 instead of half of $1,085. The Plan denied your request. The Plan says the claim was processed correctly based on the Evidence of Coverage.  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 cone beam CT are not among those covered under this benefit. The Evidence of Coverage says comprehensive dental services are covered at 50%. The record shows that the allowed amount for the root canal is $522.10. The record shows that the Plan paid 50%, or $261.05. Therefore, we decided that the Plan does not have to pay an additional amount for the limited oral evaluation (D0140), cone beam computed tomography (CT) (D0364), and root canal (D3320) provided on November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a 2D dental photographic image (D0350) provided by a participating provider on October 6, 2021.  You asked the Plan to pay for 2D dental photographic image. You say that if you would have known that this service was not covered, you would not have had the procedure done. The Plan denied your request. The Plan says the dental imaging that was provided is not a covered dental 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. Therefore, we decided that the Plan does not have to pay for a 2D dental photographic image (D0350) provided by a participating provider on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on May 13, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that services were provided to the enrollee. The Plan denied your request. The Plan says the provider is a non-participating provider, and the enrollee was not referred by a network provider.   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 May 13, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve wheelchair repairs.  You asked the Plan to pre-approve wheelchair repairs. You say that the service is medically necessary. The Plan denied your request. The Plan says the cost of repairs (including past repairs that were approved for coverage and repairs currently requested) exceeds the cost of replacement, and no payment can be made per Medicare.  The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated expense of purchasing or renting another item of equipment for the remaining period of medical need, no payment can be made for the amount of the excess   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wheelchair repairs have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair repairs.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for debridement provided on September 13, 2021, and September 27, 2021.  You asked the Plan to waive the copayments for debridement. You say that you disagree with the hospital 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 $325 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.   You received debridement at an outpatient hospital facility on September 13, 2021, and September 27, 2021. Debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $325 copayment per each visit. The total amount you owe is: $650.   You have been asked to pay the total copayment amount of $650 for debridement. Debridement falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments for debridement provided on September 13, 2021, and September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient hospital services coded as 36415, 83880, 85025 and 71046 provided October 18, 2021.  You asked the Plan to pay for the outpatient services. You say that you are submitting medical records to support medical necessity. Please review and process your claim for payment. The Plan denied your request. The Plan says the primary  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has another payer as the primary payor and the primary payor must be billed. As the secondary insurer, the Plan cannot be held responsible for the outpatient services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services coded as 36415, 83880, 85025 and 71046 provided October 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing rendered on May 4, 2021.  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 drug testing rendered on May 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response provided on August 21, 2021.  You asked the Plan to pay for this service. You say that you chose not to be transported in the ambulance and feel the Plan should pay some of it. The Plan denied your request. The Plan says the rules are clear that ambulance response with no transport is not covered by Medicare.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance provider records show you clearly refused transport. 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 ambulance response with no transport provided on August 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an arthrocentesis injection (20610), a knee orthosis (L1851, L2397), and a hyaluronan or derivative (J7320) provided from June 25, 2020, to July 14, 2020.  You asked the Plan to pay for an arthrocentesis injection, a knee orthosis, and a hyaluronan or derivative. You say that the patient did not give you the correct Medicare information. The Plan denied your request. The Plan says they did not receive the claim from the provider within the 12-month filing limit.  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 an arthrocentesis injection, a knee orthosis, and a hyaluronan or derivative was not filed until August 20, 2021. 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 an arthrocentesis injection (20610), a knee orthosis (L1851, L2397), and a hyaluronan or derivative (J7320) provided from June 25, 2020, to July 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided from August 6, 2021, to August 10, 2021.  You asked the Plan to waive the coinsurance for the inpatient hospital care. You say that the services should be covered. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided.  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 $335 copayment for days 1-6 of Inpatient Hospital Care.    The enrollee has been asked to pay a $335 copayment for three days of inpatient hospital care ($335 x 3 = $1,005). This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided from August 6, 2021, to August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a below-knee flexible cover system (L5962).  You asked the Plan to pre-approve a below-knee flexible cover system. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested item have not been met.    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 a below-knee flexible cover system. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not support that the enrollee has special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by items already approved by the Plan.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a below-knee flexible cover system have not been met. Therefore, we decided that the Plan does not have to pre-approve a below-knee flexible cover system (L5962).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on  April 6, 2021.  You asked the Plan to waive 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 the copayment has been applied correctly to the service provided.  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 $20 copayment for each Medicare-covered specialist visit.   You have been asked to pay a $20 copayment for the Medicare-covered specialist visit provided. 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 (99213) provided on April 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on July 26, 2021.  You asked the Plan to pay for a diagnostic or therapeutic injection. You say that the services at issue are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules.   Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a diagnostic or therapeutic injection have not been met. Specifically, the case record does not contain documentation to support the medical necessity of the services at issue. Therefore, we decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens(V2204), anti-reflective coating, per lens (V2750), and progressive lens, per lens (V2781) provided September 28, 2021.

You asked the Plan to provide additional payment for the routine lenses. You say that you don't understand why the billed amount is more than the amount allowed by Medicare. The Plan denied your request. The Plan says your routine eyewear benefit has been exhausted.

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 up to $100 every 2 years. 

We looked at the file and the Plan's rules. The Plan provided documentation showing that your $100 allowance was applied to your routine eyewear purchased September 28, 2021. Therefore, we decided that the Plan does not have to provide additional payment for the spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens(V2204), anti-reflective coating, per lens (V2750), and progressive lens, per lens (V2781) provided September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided by an out-of-network provider on July 26, 2021.  You asked the Plan to pay for a mandibular partial denture. You say that you were unaware that this was not a covered benefit. The Plan denied your request. The Plan says a mandibular partial denture is not a covered dental 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. Therefore, we decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided by an out-of-network provider on July 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the diagnostic colonoscopy and the Part B drugs you received during the colonoscopy at an outpatient hospital facility on September 29, 2021.  You asked the Plan to waive the cost sharing for the diagnostic colonoscopy and the Part B drugs. You say that you called the Plan prior to the service to confirm it was covered. You say that you were told it was covered.  You also say that if you had been told it was not covered, you would not have had the procedure. The Plan denied your request. The Plan says this service was covered, but the billed amount represents your cost sharing.  The Plan says that you were charged this cost sharing 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 $250 copayment for outpatient surgery and 20% coinsurance for Medicare Part B drugs.  You have been asked to pay a $250 copayment for the diagnostic colonoscopy and 20% coinsurance for the Part B drugs. The diagnostic colonoscopy falls within the outpatient surgery 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 cost sharing for the diagnostic colonoscopy and the Part B drugs you received during the colonoscopy at an outpatient hospital facility on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for urgently needed services provided on September 10, 2021, and September 17, 2021.  You asked the Plan to waive the copayments for urgently needed services. You say that you were told that you would not owe a copayment for the services. 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 $30 copayment for urgently needed services.   You received urgently needed services on September 10, 2021, and September 17, 2021. Therefore, you are responsible to pay a $30 copayment per each visit. The total amount you owe is: $60. You have been asked to pay the total copayment amount of $60 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 copayments for urgently needed services provided on September 10, 2021, and September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on June 18, 2021.  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 June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and additional periapical x-rays (D0230 x 2) provided on October 14, 2021.  You asked the Plan to pay for the dental services. You say that you had a toothache. You also say that the services are medically necessary. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that 1 periapical x-ray is covered per calendar 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, the limited oral evaluation is not among those covered under this benefit. Additionally, the Evidence of Coverage says that 1 periapical x-ray is covered per calendar year. The record shows that the Plan paid for the initial periapical x-ray that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), and additional periapical x-rays (D0230 x 2) provided on October 14, 2021.