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

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and panoramic radiographic imaging (D0330) provided by a participating provider on July 12, 2021.  You asked the Plan to pay for a limited oral evaluation and panoramic radiographic imaging. You say that you believe that the Plan should pay for this. The Plan denied your request. The Plan says the benefit limit for the services provided have 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 limited oral evaluation once every three years and panoramic radiographic imaging once every five years.  We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation and panoramic radiographic imaging have already been exhausted on February 6, 2019. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and panoramic radiographic imaging (D0330) provided by a participating provider on July 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from March 4, 2021, to March 8, 2021.

You asked the Plan to waive the copayment for the inpatient hospital care. You say that you believe that this bill is incorrect because this was not an out-of-network service. 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). Your contract with the Plan clearly says that you must pay a $290 copayment per day for days 1-5 for inpatient hospital care. 

Records show that you were in the hospital for 4 days. You were charged a $290 copayment per day, for a total of $1160. This is not an out-of-network denial, rather, this is the cost sharing owed for inpatient hospital 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 inpatient hospital care provided from March 4, 2021, to March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a tooth extraction (D7210) provided by a participating provider on June 22, 2021.  You asked the Plan to pay for a tooth extraction. You say that you were told that you had dental coverage. The Plan denied your request. The Plan says the dental services that were provided are 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 a tooth extraction (D7210) provided by a participating provider on June 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided from May 25, 2021, through May 28, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you were unable to administer the eye drops due to the severity of your condition. You say that the prescriptions issued were necessary and you would appreciate further consideration of the denial. The Plan denied your request. The Plan says self-administered medications 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 from May 25, 2021, through May 28, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite - one surface, posterior (D2391) and resin-based composite - three surfaces, posterior (D2393) provided May 11, 2021.

You asked the Plan to pay for the two resin-based composites. You say that you would like the fillings covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers two resin-based composites per calendar year. 

We looked at the file and Medicare rules. The Plan provided documentation showing that two resin-based composites were covered on the same date of service. Based on this information, we decided that the Plan's frequency limit for coverage of the two resin-based composites has been exceeded. Therefore, we decided that the Plan does not have to pay for the resin-based composite - one surface, posterior (D2391) and resin-based composite - three surfaces, posterior (D2393) provided May 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the injection procedure you had at an outpatient hospital facility on April 28, 2021.  You asked the Plan to waive the copayment for the injection procedure. You say that you cannot afford this copayment. 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 $100 copayment for outpatient procedures and services performed in an outpatient hospital.   You have been asked to pay a $100 copayment for the injection procedure. The injection procedure falls within the outpatient procedures and services performed in an outpatient hospital 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 injection procedure you had at an outpatient hospital facility on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the cost sharing for the out-of-network physical therapy services you received on April 29, 2021.  You asked the Plan to reduce the cost sharing for the out-of-network physical therapy services. You say that the provider advised you that they were in-network, so you should only have to pay the in-network cost sharing. The Plan denied your request. The Plan says this provider is out-of-network, so 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 50% coinsurance for out-of-network physical therapy services.   You have been asked to pay 50% coinsurance for the out-of-network physical therapy services. The provider from whom you received services is out-of-network.  The Plan cannot be held responsible for incorrect information provided to you by this out-of-network provider. 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 reduce the cost sharing for the out-of-network physical therapy services you received on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image (D0230) and core buildup, including any pins when required (D2950) provided December 3, 2020.

You asked the Plan to pay for the additional intraoral x-ray and core buildup. You say that you were told your services would be covered at 100%. The Plan denied your request. The Plan says you have exceeded the frequency limit for the x-rays and core buildup is not a covered service. Additionally, the Plan says that they have reviewed the call records and found that no incorrect information was provided.

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 the additional intraoral x-ray and core buildup when the services are medically necessary and reasonable. 

We looked at the file and Medicare rules. The Plan provided documentation showing that one intraoral x-ray was covered on the same date of service. Based on this information, we decided that the Plan's frequency limit for coverage of the additional intraoral x-ray and core buildup has been exceeded. Though the Plan offers a dental benefit in excess of Medicare coverage, core buildup is not among those covered services. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image (D0230) and core buildup, including any pins when required (D2950) provided December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and panoramic radiographic image (D0330) provided July 21, 2021.  You asked the Plan to pay for the limited oral exam and panoramic x-ray. You say that you were under the impression that the services would be covered. The Plan denied your request. The Plan says these services are not covered under your benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and panoramic radiographic image (D0330) provided July 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-ray exam of the lumbar spine (72110), the x-ray exam of the sacroiliac joints (72202), the transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location (R0075), and the set-up of portable x-ray equipment (Q0092) rendered by the out-of-network (OON) provider on July 19, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the x-ray exam of the lumbar spine (72110), the x-ray exam of the sacroiliac joints (72202), the transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location (R0075), and the set-up of portable x-ray equipment (Q0092) rendered by the out-of-network (OON) provider on July 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation hospital services you received from March 12, 2021, to March 26, 2021.  You asked the Plan to waive the copayment for the inpatient rehabilitation hospital services. You say that this stay was a continuation of care that began at another inpatient hospital facility.  Therefore, you believe there should be no copayment for these services. 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 $225 copayment per day for days 1-6 for inpatient hospital care.   Records show that you were admitted to an acute care hospital from March 8, 2021, to March 12, 2021. You were discharged and transferred to an inpatient rehabilitation hospital, where you remained from March 12, 2021, to March 26, 2021.  You have been charged a copayment of $225 per day for each of the first 6 days of the inpatient rehabilitation hospital stay, for a total of $1350.  According to your Evidence of Coverage, the inpatient hospital care cost sharing applies to both inpatient acute care and inpatient rehabilitation care. This cost sharing applies each time you are admitted to the hospital.  The contract goes on to say that a transfer to a separate facility type (such as an inpatient rehabilitation hospital) is considered a new admission.  That is the case here.  The facility that you were transferred to from the acute care hospital is considered an inpatient rehabilitation hospital, not a skilled nursing facility.  Your contract states that the cost sharing applies again if you change facility types. So, even though this may have been a continuation of care, separate cost sharing can apply in accordance with your contract. 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 rehabilitation hospital services you received from March 12, 2021, to March 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided to the enrollee on April 20, 2021.  You asked the Plan to pay for the genetic testing. You say that the services were necessary. The Plan denied your request. The Plan says your request for genetic testing does not meet the requirements for approval of the claim to be paid.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. The enrollee's medical records show they do not have any inherited type of cancers such as breast or ovarian. Also, the enrollee does not have any acquired cancers that are recurrent, relapsed, refractory, metastatic, or advanced stage III or IV. Therefore, we decided that the Plan does not have to pay for the genetic testing provided to the enrollee on April 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rotary wing, air ambulance transport (A0436), and air mileage (A0431) provided on May 7, 2021.  You asked the Plan to pay for the air ambulance services. You say that the air ambulance was requested to expedite transport and to provide acute care in route. You say that the enrollee required emergent transport for higher level of gastrointestinal (GI) services not available at the referring facility. The Plan denied your request. The Plan says transport to the nearest tertiary facility was not provided. The Plan says that there were closer tertiary facilities available to provide the necessary care.  The Plan follows Medicare rules. The rules say that Medicare pays for ambulance services to the nearest appropriate facility.   We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the air ambulance services have not been met. Specifically, the file shows that the facility that the enrollee was transported to was not the nearest appropriate facility. Therefore, we decided that the Plan does not have to pay for the rotary wing, air ambulance transport (A0436), and air mileage (A0431) provided on May 7, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the inpatient services provided from April 23, 2019, to April 29, 2019.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed diagnosis code is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with diagnosis code N17.9. 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 services. Our reviewer says that the billed diagnosis code and DRG in this case are supported by the records provided. Our physician reviewer found that the enrollee did meet accepted criteria for acute renal failure. Acute renal failure is associated with worse outcomes and is a notable escalation in the severity of illness being associated with higher mortality and longer hospitalization.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the inpatient services provided from April 23, 2019, to April 29, 2019.   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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for Guardant360 testing provided on July 13, 2021.  You asked the Plan to pay for genetic testing. You say that this testing was ordered by the enrollee's treating physician to determine the optimal treatment pathway for the enrollee. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Guardant360 requires the use of a single code 81479 but this testing was billed with 32 separate procedure codes.  The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with single procedure code 81479 applicable to date of service July 13, 2021.   We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye exam (92004), an eye refraction (92015), an eye exam with photos (92250), anti-reflective coating (V2750), deluxe frames (V2025) and progressive lenses (V2781) provided on September 17, 2020, to September 22, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for an eye exam, an eye refraction, an eye exam with photos, anti-reflective coating, deluxe frames, and progressive lenses. You say that you were told that you would receive reimbursement because the provider was not willing to file a claim due to the OON status of the provider. You also say you were given incorrect information and would like to be reimbursed. The Plan denied your request. The Plan says you do not have OON benefits. The Plan also says that the provider was OON for this date of service and did not become active until May 28, 2021.  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 when they are obtained through one of the Plan's routine vision service vendors.  We looked at the file and the Plan's rules. The records show that the service at issue was provided by an out-of-network provider. This service is not covered by the Plan when provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of an eye exam, an eye refraction, an eye exam with photos, anti-reflective coating, deluxe frames and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam (92004), an eye refraction (92015), an eye exam with photos (92250), anti-reflective coating (V2750), deluxe frames (V2025) and progressive lenses (V2781) provided on September 17, 2020, to September 22, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for SelectMDx testing provided on July 7, 2021.  You asked the Plan to pay for laboratory testing. You say that you are the sole provider of this test. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because there was no documented result of prior prostate biopsy or significant interval increase in prostate-specific antigen (PSA) level.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.  This testing was ordered by an in-network provider. The file does not show that the plan provided notice that laboratory testing would not be covered. Under Medicare rules, this means laboratory testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for SelectMDx testing provided on July 7, 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.