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

We decided that the Plan does not have to pay for the panoramic x-ray, additional intraoral x-ray and limited oral evaluation provided on July 6, 2021.
You asked the Plan to pay for the panoramic x-ray, additional intraoral x-ray and limited oral evaluation. You say that you were told you were covered for x-rays. You say that you don't feel that you owe this amount and hope the bill can be canceled. The Plan denied your request. The Plan says the claim processed correctly.
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 also have a maximum benefit of one intraoral x-ray per calendar year and one panoramic x-ray every five years. The Plan paid for the panoramic x-ray provided on July 11, 2018 and paid for one intraoral x-ray provided on July 6, 2021, which exhausted your benefits. The limited oral evaluation remains denied as a non-covered benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray, additional intraoral x-ray and limited oral evaluation provided on July 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from August 12, 2021, to August 13, 2021.
You asked the Plan to pay for the self-administered drugs. You say that the services should be covered. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says
self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from August 12, 2021, to August 13, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on July 13, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you only took what was prescribed by the doctor and you don't understand the denial for the drugs. The Plan denied your request. The Plan says self-administered drugs are not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950), and 2D oral or facial photographic image (D0350) provided on August 2, 2021.
You asked the Plan to pay for the dental services. You say that your plan provides reimbursement for 3 crowns and 1 build up per calendar year. You also say that you feel the same number of crowns and core build up should be covered per year. The Plan denied your request. The Plan says 1 core build up is covered per year. The Plan says that the frequency limit has been reached. The Plan also says that 2D oral or facial photographic image 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 and core build up is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a core build up received on January 27, 2021. Additionally, the 2D oral or facial photographic image is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950), and 2D oral or facial photographic image (D0350) provided on August 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from August 16, 2021, to August 27, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you don't feel you should have been discharged from a previous hospital stay and you shouldn't have to pay a copayment for this stay. 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 $300 copayment per day for days 1-5 of inpatient hospital care each time you are admitted to a hospital.
You have been asked to pay a total of $1,500 ($300 copayment x 5 days = $1,500) for the inpatient hospital services. The inpatient hospital services fall 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 hospital admission and services provided from August 16, 2021, to August 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on August 24, 2021.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you didn't know the dental provider was out-of-network and the claim should be covered. The Plan denied your request. The Plan says dental services are only covered when received by a participating provider.
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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on August 24, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient mental health hospital stay provided by a participating provider on August 9, 2021, to September 14, 2021.
You asked the Plan to waive the copayment for an inpatient mental health hospital stay. You say that this copayment is way too high. You say that you do not feel like you should be responsible for this. 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 $395
copayment per day for days 1-4. There is a $0 copayment per day for days 5-90 for inpatient mental health care. You have been asked to pay a $395 copayment per day for days 1-4. There is a $0 copayment for additional days for an inpatient mental health hospital stay. The total amount you are being asked to pay is $1,580 ($395 x 4 days = $1,580). An inpatient mental health hospital stay falls within the inpatient mental health 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 an inpatient mental health hospital stay provided by a participating provider on August 9, 2021, to September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-rays (D0274) provided on May 26, 2020.
You asked the Plan to pay for the comprehensive exam and x-rays. You say that you live on a fixed income and are frustrated with this denial of services. The Plan denied your request. The Plan says these services are not covered by your 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 the comprehensive oral evaluation (D0150) and bitewing x-rays (D0274) provided on May 26, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on August 11, 2020.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the code is not appropriate for the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on August 11, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the cholecystostomy (47490), and abdominal ultrasound (76705) provided from April 26, 2021, to April 27, 2021.
You asked the Plan to pay for the outpatient services. You say that the services rendered are not related to the enrollee's hospice diagnosis. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the cholecystostomy (47490), and abdominal ultrasound (76705) provided from April 26, 2021, to April 27, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the transtelephonic monitoring (93293) provided on August 24, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the transtelephonic monitoring. You say that the services were medically necessary. The Plan denied your request. The Plan says the services do not meet criteria for OON coverage.
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 the transtelephonic monitoring (93293) provided on August 24, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on May 10, 2021.
You asked the Plan to pay for the dental services. You say that you were told the services would be covered. You also say that you were surprised when the dental office informed you that you did not have coverage. The Plan denied your request. The Plan says the dental services you received are routine in nature. The Plan also says that routine dental services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Additionally, the record shows that you did not sign up for the optional supplemental dental coverage. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on May 10, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper and lower dentures (D5120, D5110) provided on June 8, 2021.
You asked the Plan to pay for the dentures. You say that you called the Plan's customer service multiple times and were given information for a few providers. None of these providers were taking new patients, except for one who required a large up-front cost. You say you contacted the Plan when you found a dental provider who could perform the work you needed, but you were not informed at any point that this provider was out-of-network. The Plan denied your request. The Plan says the provider in this case is not part of your dental network. Out-of-network dental care is 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. If you receive services out-of-network, you are responsible for 100% of the cost.
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received out-of-network are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete upper and lower dentures (D5120, D5110) provided on June 8, 2021.
Your complaint about the availability of in-network dental providers and a possible miscommunication or misinformation from the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) provided on August 27, 2021.
You asked the Plan to pay for scaling and root planing. You say that your provider told you this service was necessary and refused to provide the standard cleaning. You feel this service should be covered because you saw an in-network provider and they refused to provide the covered service. The Plan denied your request. The Plan says this service is not covered by your 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 the periodontal scaling and root planing (D4341) provided on August 27, 2021.
Your complaint about the services provided by an in-network provider and the Plan's covered services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room service provided on August 8, 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $75 copayment for Medicare-covered emergency services. The enrollee has been asked to pay a $75 copayment for the Medicare-covered emergency services provided. 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 the emergency room service provided on August 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, panoramic x-ray and complete upper denture provided on July 14, 2021.
You asked the Plan to pay for the periodic oral evaluation, panoramic x-ray and complete upper denture. You say that you called the Plan to find out where to go and you didn't think to ask if the doctor was in-network. You say that you can't eat without teeth and don't understand why they aren't paying. The Plan denied your request. The Plan says out-of-network services 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, panoramic x-ray and complete upper denture provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a contracted provider on September 3, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that your old dentist had criminal charges. The Plan denied your request. The Plan says the benefit limit for D0150 has already 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. The Plan covers a comprehensive oral evaluation when the service once every three years. We looked at the file and Medicare rules. Evidence was provided to show that a comprehensive oral evaluation was provided on August 18, 2020. Based on this information, we decided that the Plan's rules for coverage of a
comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a participating provider on September 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0428) provided on August 6, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that these services were necessary. The Plan denied your request. The Plan says these services are covered, and this claim was processed correctly. You are responsible for a $325 copayment for covered ambulance services. The Plan's allowed amount (discounted rate) in this case is less than your required copayment, so you are responsible for $303.88 for this service.
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 ambulance services.
You have been asked to pay a $303.88 copayment for the ambulance transportation. 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 transportation services (A0428) provided on August 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0425, A0429) provided on April 23, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that this service was medically necessary, and you cannot afford this cost. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. Ambulance services require a $225 copayment.
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 ambulance services.
You have been asked to pay a $225 copayment for the ambulance transportation. 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 transportation services (A0425, A0429) provided on April 23, 2021.