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

We decided that the Plan does not have to pay for the skilled nursing services provided from June 28, 2021, to July 4, 2021.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee elected Hospice on June 28, 2021. The Plan also says that while on hospice, Skilled Nursing Facility (SNF) level benefits are not covered by the Plan.

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 skilled nursing services provided from June 28, 2021, to July 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay for the eye exam and refraction provided on May 14, 2021.

You asked the Plan to fully pay for the eye exam and refraction. You say that you were dissatisfied with your former eye care establishment, so you went to this provider. You say that you never heard about going to a network provider and the bill should qualify for coverage. The Plan denied your request. The Plan says the claim processed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $45 for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye. A refraction is only covered as necessary with a routine vision exam. 

You have been asked to pay a $45 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The refraction is not covered as a medical eye exam was performed. 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 fully pay for the eye exam and refraction provided on May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0272), and prophylaxis (D1110) provided on June 16, 2021.

You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis. You say that you would like these services to be covered. The Plan denied your request. The Plan says that these services are not covered expenses under your dental 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. 

We looked at the file and Medicare rules. There is no documentation provided showing that the comprehensive oral evaluation, bitewing x-rays, or prophylaxis benefits have been exhausted. The 2021 Evidence of Coverage also does not clearly state what types (or codes) of bitewing x-rays are covered. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral evaluation, bitewing x-rays, and prophylaxis have been met. Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0272), and prophylaxis (D1110) provided on June 16, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 24, 2021.

You asked the Plan to pay for procedure code 70450. You say that multiple services were performed on this date. The Plan denied your request. The Plan says payment for this code is bundled into another code on the same date.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code procedure code 70450 is a column II code to column I code 70496.

This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional tooth for dentures (D5650) provided by a participating provider on August 10, 2021.
You asked the Plan to pay for an additional tooth for dentures. You say that the dentist you saw was in-network. The Plan denied your request. The Plan says the enrollee's annual maximum benefit of $1,000 had already been met.
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 an annual maximum benefit amount of $1,000 for dental services.
We looked at the file and Medicare rules. Evidence was provided that shows the annual maximum benefit amount of $1,000 was met in May. Based on this information, we decided that the Plan's rules for an annual maximum benefit amount of $1,000 have already been met. Therefore, we decided that the Plan does not have to pay for an additional tooth for dentures (D5650) provided by a participating provider on August 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional Modivcare mileage.
You asked the Plan to pre-approve additional mileage. You say that you need to see this specialist as soon as possible. You also say that if you wait any longer, it can cause you harm. The Plan denied your request. The Plan says you are requesting an additional 23 miles for a total of 73 miles and your benefit only allows 50 miles. The Plan also says you have exceeded your benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to 12 one-way trips and each one-way trip must not exceed 50 miles of driving distance.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0366) provided on June 30, 2021.

You asked the Plan to pay for the dental service. You say that you have a life-threatening vasculitis disease. You say that the pain can come from the teeth or sinuses as you have some cracked teeth. You say that you were advised you needed to see an endodontist. You say that the closest one available was 2 hours away. You also say that you were advised by a plan representative that you could go out of network for this service. The Plan denied your request. The Plan says cone beam CT capture with interpretation 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 cone beam CT capture with interpretation not among those covered under this benefit, regardless of the provider's network status. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0366) provided on June 30, 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 August 4, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you were exposed to rabies by a bat, so your primary care doctor sent you to the ER because they did not carry the rabies vaccine. 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 emergency room visits.
You have been asked to pay a $50 copayment for the ER visit. The ER copayment applies regardless of the reason for the 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 August 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the x-ray you had on January 30, 2021, the transthoracic echocardiography (TTE) you had on March 29, 2021, and the spirometry test you had on May 11, 2021.

You asked the Plan to waive the copayments for the x-ray, the TTE, and the spirometry test. You say that this was related to post-COVID symptoms, so the copayments should be waived. The Plan denied your request. The Plan says there was no copayment waiver in effect at the time of these services.

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 x-rays, $160 for radiological diagnostic services, and $30 for non-radiological diagnostic services.

You have been asked to pay a $30 copayment for the x-ray, the TTE, and the spirometry test. The TTE is a radiological diagnostic service and the spirometry test is a non-radiological diagnostic service. Please note that the Plan's website explicitly states that the Plan is no waiving cost sharing for COVID-19 treatment. The website states that you will be responsible for cost sharing according to your benefit plan for COVID-19 treatment. 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 the x-ray you had on January 30, 2021, the transthoracic echocardiography (TTE) you had on March 29, 2021, and the spirometry test you had on May 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-emergent ambulance transportation services (A0428) provided on July 30, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that you had no choice in the method of transportation and feel if you had been transported by other means you could have saved more money. The Plan denied your request. The Plan says this claim was processed correctly, and your cost-sharing was assessed in accordance with your contract. You are being asked to pay less than the full $325 ambulance copayment because the discounted/allowed cost is less than $325.

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 $290.38 copayment for the ambulance services. 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 non-emergent ambulance transportation services (A0428) provided on July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided from June 1, 2021 to June 3, 2021.

You asked the Plan to pay for these services. You say that you feel the Plan should pay for these services. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.

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 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 out of network physician services provided from June 1, 2021 to June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the pneumatic walking boot you received on July 10, 2021.

You asked the Plan to waive the coinsurance for the pneumatic walking boot. You say that you don't think you should have to pay for this since you did not use it and you want to return it. 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 durable medical equipment. 

You have been asked to pay 20% coinsurance for the pneumatic walking boot. The pneumatic walking boot falls within the durable medical equipment benefit category. This coinsurance applies each time you receive an item, regardless of whether or not you use it. 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 pneumatic walking boot you received on July 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 29, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network physician services provided to the enrollee on June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) for tooth # 1 provided on August 20, 2021.

You asked the Plan to pay for the dental service. You say that you received a simple extraction. You say that this is covered by your insurance. You also say that even though it was a wisdom tooth that was extracted, it only took a few minutes and there were no stitches or pain medication. The Plan denied your request. The Plan says the extraction 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 extraction is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction (D7140) for tooth # 1 provided on August 20, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from June 5, 2021, through July 4, 2021.

You asked the Plan to pay for the SNF services. You say that it is felt that Medicare pay should be made for these services. The Plan denied your request. The Plan says this was custodial care and correctly denied for Medicare reimbursement.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary was a 78-year-old male with pneumonia, dementia, chronic obstructive pulmonary disease, diabetes, and congestive heart failure. From a nursing perspective, the beneficiary received oral and inhaled medications. The beneficiary had stable vital signs. He was treated for a right great toe infection. Regarding rehabilitation services, the beneficiary received speech therapy. He tolerated a dysphagia diet and thin liquids. 

There are no identifiable skilled therapy service needs. There are no identifiable skilled nursing service needs. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from June 5, 2021, through July 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased on August 19, 2021.

You asked the Plan to pay for the eyeglasses. You say that your booklet says an eyewear allowance is provided every calendar year for eyewear to correct vision. You say that the last pair of glasses you purchased was in 2017 and the error should be corrected to apply your $250 allowance to the purchase. The Plan denied your request. The Plan says your optical frame allowance 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 up to $250 every calendar year for eyewear. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for additional coverage of the eyeglasses have not been met. Specifically, the Plan has already paid $250 toward the eyeglasses. Therefore, we decided that the Plan does not have to pay more for the eyeglasses purchased on August 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2750, V2784, V2781, V2020) purchased on August 23, 2021, from an out-of-network provider.
You asked the Plan to pay for the eyeglasses. You say that the eyeglasses should have been covered in full. The Plan denied your request. The Plan says this claim was processed correctly, and your benefits were applied in accordance with your contract. The provider in this case is not part of the Plan's network, and the Plan has paid the full $35 allowed for frames and $35 allowed for lenses. The remaining cost is your responsibility.
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 up to $35 for one pair of frames every 24 months and up to $35 for one pair of prescription eyeglass lenses every 12 months from an out-of-network provider. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's network. Documentation shows that the Plan has already paid the full allowance for routine vision services purchased out-of-network. Based on this information, we decided that Plan does not have to pay any additional amount for the eyeglasses (V2750, V2784, V2781, V2020) purchased on August 23, 2021, from an out-of-network provider.