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

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on June 3, 2021.
You asked the Plan to pay for the x-rays. You say that you were told this service would be covered and do not
understand why you are responsible for these charges. The Plan denied your request. The Plan says your
benefit covers one set of bitewing x-rays per calendar year. You received a previous set of bitewing x-rays in
March of 2021, which was paid for by the Plan. Therefore, the x-rays provided on the date in question exceed
the limitations of your benefit and will not be 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. The Plan can cover one set of
bitewing x-rays per calendar year.
Though the Plan offers a dental benefit in excess of Medicare coverage, the x-rays are requested in a frequency
that exceeds what is covered under this benefit. Documentation shows that the Plan paid for a previous set of
bitewing x-rays you received in March 2021. Therefore, we decided that the Plan does not have to pay for the
bitewing x-rays (D0274) provided on June 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $150 copayment charged for ambulance transport 
provided on May 11, 2021. 
 
You asked the Plan to waive this copayment. You say that you do not believe you owe this copayment because 
you were incorrectly dosed by an allergy clinic, which caused the need for ambulance transport. The Plan 
denied your request. The Plan says this copayment is a contractual obligation. 
 
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 $150 
copayment for each one-way ambulance transport. 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 $150 
copayment charged for ambulance transport provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 13, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you were prepared to pay your $15 copay, but you were billed $151.00 more than what the insurance paid. The Plan denied your request. The Plan says this procedure exceeds the frequency limitation in your benefit 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, you are limited to one comprehensive evaluation per 36 months. The record shows that you received a comprehensive oral evaluation (D0150) on January 9, 2020 and your comprehensive evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic (D6245) and two retainer crowns (D6740 x2)
provided on June 7, 2021.
You asked the Plan to pay for the pontic and retainer crowns. You say that you would like the Plan to pay the
equivalent of two crowns. The Plan denied your request. The Plan says these 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, 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 pontic
(D6245) and two retainer crowns (D6740 x2) provided on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a wrist hand orthosis (L3908) provided on 
May 21, 2021. 
 
You asked the Plan to waive the coinsurance for a wrist hand orthosis (L3908). You say that you were not 
advised you would be billed separately. You also say that you were not happy to receive this bill. 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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Durable Medical Equipment (DME) and Related Supplies.  
 
You have been asked to pay a total of $11.01 in coinsurance for a wrist hand orthosis (L3908), which is 20% of 
the allowed amount ($55.03 allowed amount x 20% coinsurance = $11.01). A wrist hand orthosis (L3908) falls 
within the Durable Medical Equipment (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 a wrist hand orthosis (L3908) provided on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an out of network consultation with the Provider 
You asked the Plan to pay for out of network providers. You say that you prefer to see the requested Provider. 
The Plan denied your request. The Plan says this treatment can be provided in network. 
 
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 an out of network 
consultation with the Provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that records do not show a need for an intensive program with a team of
health care professionals and doctors that specialize in complex medical needs or an interdisciplinary team
approach to the delivery of rehabilitation care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care.
Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on
Medicare guidelines. Documentation does not support the need for therapy program consisting of at least 3
hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care.
There are no documented skilled nursing needs. While you may benefit from physical and occupational
therapy, your rehab needs can be safely met in an alternate and low intensity setting such as in an SNF. Our
physician reviewer found that your condition does not meet Medicare criteria for IRF care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a core buildup (D2950) provided by a participating provider on June 17, 2021.

You asked the Plan to waive the coinsurance for a core buildup. You say that you believe the Plan should pay a 50% coinsurance. The Plan denied your request. The Plan says the correct coinsurance 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 70% coinsurance for dental services/in-network. 

You have been asked to pay a 70% coinsurance of the allowed amount for a core buildup. The total allowed amount is $190. The total amount you are being asked to pay is $133 ($190 x 70% = $133). A core buildup falls within the dental services/major restorative services/in-network 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 a core buildup (D2950) provided by a participating provider on June 17, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided from February 3, 2021, through
February 8, 2021.

You asked the Plan to pay for hospital services. The Plan denied your request. The Plan says Original Medicare
would be responsible for payment of all Medicare covered services related or unrelated to the member's
terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care
from the effective date of election to the date of discharge or revocation. During the election, fee-for-service
Medicare also covers attending physician services and all care unrelated to the terminal illness until the first
day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on February 3, 2021. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital services
provided from February 3, 2021, through February 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on April 16, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that your life was saved. You say that this 
service should have been covered. You also say that your recent hospitalization proved this. The Plan denied 
your request. The Plan says the ambulance benefit is a transportation benefit. The Plan says that since there was 
no transportation provided, the service is not covered. 
 
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 April 16, 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 the ambulance response and treatment, no 
transport, (A0998) provided on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services rendered on January 26, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 32 POS 
code. Therefore, we decided that the Plan does not have to pay for the medical services rendered on January 26, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to waive the $25 copayment for specialist services.  
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment is a contractual obligation. 
 
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 $25 
copayment for specialist services. 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 $25 copayment for specialist services provided 
on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on April 2, 2021.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were not informed of the additional cost. 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 Medicare Part B prescription drugs. 

You received Medicare Part B drugs on April 2, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $3,122.60 and 20% of that is $624.52. 

You have been asked to pay the total coinsurance amount of $624.52 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 Medicare Part B drugs provided on April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 13, 2021.

You asked the Plan to pay for the services provided. You say that the documentation supports the service was
separate. The Plan denied your request. The Plan says the claim processed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.

We find that CPT code 99213 was billed with modifier XU. The medical records do not indicate that the proper
criteria for use of the modifier were met. Based on this information, we decided that Medicare rules for
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay
for the office visit provided on May 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin injections provided on November 10, 2020.
You asked the Plan to pay for the vitamin injections. You say that this is not a duplicate and medical records are attached. You say that the claim should be reviewed and reprocessed for additional payment. The Plan denied your request. The Plan says the original decision to deny payment is correct.
The Plan must follow Medicare rules. Medicare rules say that in order for physician-provided drugs to be covered, the medical records must document the name of the drug administered as well as the dosage. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the vitamin injections have not been met. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Therefore, we decided that the Plan does not have to pay for the vitamin injections provided on November 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on June 8, 2021.

You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 laboratory services provided on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on June 4, 2021.  
 
You asked the Plan to pay for these services. You say that you were referred for these services. The Plan 
denied your request. The Plan says there is neither a referral nor prior authorization for this service on record.  
 
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 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 on June 4, 2021
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 6 home health skilled nursing visits. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 6 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
documentation does not support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing services to 
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
documentation of the wound indicates that there is no infection or need for additional skilled services. The 
requested home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 home health skilled nursing visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $315 copayment charged for ambulance transport provided on February 17, 2021.

You asked the Plan to waive copayment. You say that no one told you there would be a copayment. The Plan denied your request. The Plan says this copayment is clearly stated in the Plan contract.

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 $315 copayment for each one-way ambulance transport. 

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 $315 copayment charged for ambulance transport provided on February 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
You asked the Plan to pre-approve the non-emergency transportation. You say that you feel the Plan should
approve additional rides because you were never told you only have 10 rides. The Plan denied your request.
The Plan says you have used 10 out of the 10 trips you are allowed per year. The Plan also says that additional
trips are not covered.
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 a maximum of up to 10 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).