Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator provided on May 26, 2021.
You asked the Plan to waive the coinsurance for an automatic external defibrillator. You say that you disagree with the charges because you only had the device one day. 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 20% coinsurance for DME and related supplies. You received an automatic external defibrillator on May 26, 2021. The total allowed amount is $2,931.45 and 20% of that is $586.29.
You have been asked to pay the total coinsurance amount of $586.29 for an automatic external defibrillator. An automatic external defibrillator falls within the DME and related 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 coinsurance for an automatic external defibrillator provided on May 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic occupational exercises provided from
March 2, 2020, through March 20, 2020.
You asked the Plan to pay for therapeutic occupational exercises. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 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 therapeutic occupational exercises provided from March 2, 2020, through March 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July
13, 2021.

You asked the Plan to pay for a comprehensive oral evaluation. You say that the service at issue should be
covered. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded
the frequency limit of one every 36 months.

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. Based on this information, we decided that the Plan's rules for
coverage of a comprehensive oral evaluation have not been met. Specifically, the record shows that you had
exceeded the frequency limit prior to this service on May 6, 2020. Therefore, we decided that the Plan does not
have to pay for a comprehensive oral evaluation (D0150) provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020), progressive lenses (V2781) and anti-reflective coating (V2750) provided on April 1, 2021. You asked the Plan to pay for eyeglass frames, progressive lenses and anti-reflective coating. You say that your Plan allows a $200 allowance for eyewear. The Plan denied your request. The Plan says eyeglasses will only be covered when they are received from a provider in the specified vision network.
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 contract says that you receive a $200 allowance for supplemental eye wear every year. Eye wear must be obtained from a provider in the routine vision network. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. The Plan covers eyewear when they are received from a provider who participates in the Plan's specified vision network Based on this information, we decided that the Plan's rules for coverage of eyeglass frames, progressive lenses and anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020), progressive lenses (V2781) and anti-reflective coating (V2750) provided on April 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
April 26, 2021, to May 5, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that these copayments 
should be waived as some compensation for the pain and suffering the enrollee experienced in the hospital. The 
Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $260 copayment per day for days 1-4, and a $0 copayment for additional days for inpatient hospital services. The enrollee has been asked to pay a $260 copayment per day for days 1-4, and a $0 copayment for additional 
days for the inpatient hospital services, for a total of $1040. 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 services provided from April 26, 2021, to May 5, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review. 
services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded as 99291 provided on March 12, 2021.
You asked the Plan to pay for the critical care services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the billed services were not supported in the medical records submitted.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically the medical records do not include documentation of the critical care time spent on this patient.. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded as 99291 provided on March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) rendered
by the out-of-network (OON) provider on December 7, 2020.
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 unlisted molecular pathology procedure (81479) rendered by the out-of-network
(OON) provider on December 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible applied to lab services you received on May 28, 2020.
You asked the Plan to waive the deductible applied to the lab services. You say that this deductible should be waived because they are related to a physical exam and are preventative. The Plan denied your request. The Plan says you had not met your deductible at the time of these services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $110 deductible which applies to lab services. The deductible applies to lab services, regardless of whether or not they are related to a physical exam. In fact, your Evidence of Coverage explicitly states that annual physical exams do not include lab services and that separate cost sharing applies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $110 deductible which applies to lab services. This cost sharing is a contractual obligation that had not been met at the time the lab services was received on May 28, 2020. Therefore, we decided that the Plan does not have to waive the deductible applied to lab services you received on May 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998,
A0425) provided on May 10, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you shouldn't be
charged for the services. The Plan denied your request. The Plan says the Medicare ambulance benefit is a
transportation benefit, if no transport occurs, there is no Medicare
covered 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 May 10, 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 ambulance response and treatment, no transport
(A0998, A0425) provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine rendered on March 10, 2020 to May 11, 2020.
You asked the Plan to pay for these services. You say that you were advised the services would be covered with a copayment. The Plan denied your request. The Plan says the services are not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to these services.
Therefore, we decided that the Plan does not have to pay for the shingles vaccine rendered on March 10, 2020 to May 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the alveoloplasty procedures (D7310, D7311), extractions (D7140), removal of residual tooth roots (D7250) and deep sedation/general anesthesia (D9222, D9223) provided on April 22, 2021.
You asked the Plan to pay for the dental services. You say that these services were medically necessary, and you cannot afford this bill as you live on a fixed income. The Plan denied your request. The Plan says You have exceeded your $3,000 benefit limit for dental care in 2021. You are responsible for all costs that exceed the annual maximum.
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 can cover up to $3,000 for covered dental services each year. Though the Plan offers a dental benefit in excess of Medicare coverage, the items or services exceed the Plan's annual benefit limit. Documentation shows that the Plan has paid the full $3,000 for your dental care in 2021. Therefore, we decided that the Plan does not have to pay for the alveoloplasty procedures (D7310, D7311), extractions (D7140), removal of residual tooth roots (D7250) and deep sedation/general anesthesia (D9222, D9223) provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on June 9, 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 (99203) rendered by the out-of-network (OON) provider on June 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided from March 19, 2021, through April 14, 2021.

You asked the Plan to pay for the additional supplies and materials. You say that code 99072 was established to report additional practice expenses incurred during a public health emergency including supplies and additional clinical staff time. You say that the claims should be reprocessed. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.

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, the CPT Code Manual definition of code 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided from March 19, 2021, through April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy (D3320) provided on October 29, 2020.

You asked the Plan to pay for the endodontic therapy (D3320). You say that you think the claim was rejected
because the dentist was out-of-network. You say that this should be reviewed because this might be covered.
The Plan denied your request. The Plan says the service is not a covered 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
endodontic therapy (D3320) provided on October 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transports provided on December 17, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that the Plan told you not to pay the second ambulance trip because your father was not admitted to the hospital. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $275 copayment for each one-way ambulance trip. The enrollee has been asked to pay a $275 copayment for the first ambulance transport. The cost sharing for the second transport is $233.81, which is less than the $275 copayment. Ambulance transport falls within the
Ambulance Services 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 the ambulance transports provided on December 17, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit provided on April 16, 2020.
You asked the Plan to pay for the outpatient visit. The Plan denied your request. The Plan says that the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the Plan.
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 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 an outpatient visit provided on April 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray (D0220) and tooth extraction (D7210) provided on May 6, 2021.
You asked the Plan to pay for the x-ray and extraction. You say that you thought your new plan had more coverage than your old plan and believed these services would be covered. The Plan denied your request. The Plan says these services are not covered by your dental benefit. The Plan also says that they reviewed your call logs and found that you did compare plans and coverage, but did not discuss the Plan you are enrolled in.
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 intraoral x-ray (D0220) and tooth extraction (D7210) provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on May 12, 2021.
You asked the Plan to pay for the dental guard. You say that this provider is in-network, and you should not owe anything for these services. The Plan denied your request. The Plan says they have agreed to cover the other dental care, but an occlusal guard is not covered by your dental benefit regardless of the participation status of the 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, 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 occlusal guard (D9944) provided on May 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nuclear medicine studies provided on May 17, 2021, and May 18, 2021.
You asked the Plan to waive the copayment for nuclear medicine studies. You say that you should only owe one copayment and not two because the test had to be done over two days. 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 $110 copayment for advanced imaging services. You received a nuclear medicine study on May 17, 2021. Therefore, you are responsible to pay the $110 copayment.
You received a nuclear medicine study on May 18, 2021. Therefore, you are responsible to pay the $110 copayment. The total amount you owe is: $220. You have been asked to pay the total copayment amount of $220 for nuclear medicine studies. Nuclear medicine studies fall 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 nuclear medicine studies provided on May 17, 2021, and May 18, 2021.