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

 We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, and preventive procedure provided on October 1, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, and preventive procedure. You say that you told the dentist you were only at the appointment for a cleaning, and not x-rays. You also say that the provider was listed in your Plan documents and the office told you they were in-network. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that non-emergency services provided by an OON provider are not available with this 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, the requested items or services are not covered when they are received OON. The record shows that the Plan contacted the provider and they advised that you were told they were in-network, but they went by the facility being in-network and not the individual provider you saw. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, and preventive procedure provided on October 1, 2021 by an out-of-network (OON) provider.   Your complaint about being provided with more than just a cleaning and possibly mischarged is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to issue reimbursement for the ophthalmological services rendered by the out-of-network (OON) provider from July 16, 2021, through August 3, 2021.  You asked the Plan to issue reimbursement. 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 issue reimbursement for the ophthalmological services rendered by the out-of-network (OON) provider from July 16, 2021, through August 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transportation (A0429) provided on June 4, 2021.  You asked the Plan to pay for the ground mileage and emergency ambulance transportation. You say that a valid procedure code was submitted and should be considered for payment. The Plan denied your request. The Plan says the enrollee was at an inpatient hospital status between June 2, 2021, and the discharge date of June 5, 2021.  The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital, it may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care while the beneficiary maintains inpatient status with the original provider. This movement of the patient is considered "patient transportation" and is covered as an inpatient hospital service.    We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ground mileage and emergency ambulance transportation have not been met. Specifically, the record shows that the enrollee was admitted as inpatient to the origin location provider from June 2, 2021, to June 5, 2021. The record also shows that the enrollee was transported to another provider while maintaining inpatient status with the original provider. This means that the ambulance service is covered as an inpatient hospital service and is not separately billable. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transportation (A0429) provided on June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on August 4, 2021 by a Medicare opt out provider.  You asked the Plan to pay for the prophylaxis. You say that your policy states that you have dental insurance for two dental cleanings per year. You also say that it does not state which dental practice you must use. The Plan denied your request. The Plan says you got this service from a provider who chose not to receive Medicare funds. The Plan also says that the treating provider opted out of Medicare effective February 3, 2021, to February 3, 2023.  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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on August 4, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided November 18, 2021.  You asked the Plan to pay for the full mouth debridement. You say that you would like the Plan to cover the cleaning part of this service. The Plan denied your request. The Plan says this service is not covered under your benefits. The Plan additionally states that they called the provider's office to confirm that no routine cleaning was performed on this date of 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 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 full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory services provided on April 15, 2021.  You asked the Plan to waive the copayment for the laboratory services. You say that blood work was not performed or drawn in a hospital setting. You say that the Evidence of Coverage shows a $0 copayment for lab work in a primary care office setting. The Plan denied your request. The Plan says the copayment applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for laboratory services at an in-network outpatient hospital.     You have been asked to pay a $40 copayment for laboratory services at an in-network outpatient hospital. for the laboratory services. the laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the laboratory services were billed by the hospital. 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 laboratory services provided on April 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug test (G0483) rendered by the out-of-network (OON) provider on June 8, 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 drug test (G0483) rendered by the out-of-network (OON) provider on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and panoramic x-ray (D0330) provided on October 12, 2021.  You asked the Plan to pay for the dental services. You say that you could not afford what the dentist wanted to do. You say that you went for a second opinion. You say that you you were given a new plan that was cheaper and involved repairing your teeth. You say that the second opinion proved to be more cost efficient. You also say that you feel you should not owe for the service. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 calendar years. The Plan says that 1 panoramic x-ray is covered every 5 years. The Plan also says that these frequency limits have been exceeded.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and panoramic x-ray that you received on August 9, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and panoramic x-ray (D0330) provided on October 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for telehealth office visits provided by an in-network provider from April 27, 2021, to August 19, 2021.  You asked the Plan to waive the copayments for the telehealth office visits. You say that you were not informed the copayment waiver of 2020 had ended. The Plan denied your request. The Plan says you have been asked to pay 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 a $35 copayment for each specialist visit.     You have been asked to pay a $35 copayment for the telehealth office visits on each date of service. The telehealth office visits fall within the "Physician/Practitioner services, including doctor's office visits" 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 copayments for telehealth office visits provided by an in-network provider from April 27, 2021, to August 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the two dimensional (2D) oral/facial photographic images (D0350), caries risk assessment and documentation (D0603), and oral hygiene instructions (D1330) provided on June 30, 2021.  You asked the Plan to pay for the 2D oral/facial photographic images, caries risk assessment and documentation, and oral hygiene instructions. You say that you never requested the services that are being denied. You also say that you went in for a covered checkup and cleaning, and you are not sure why the dentist billed for the additional services. 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 two dimensional (2D) oral/facial photographic images (D0350), caries risk assessment and documentation (D0603), and oral hygiene instructions (D1330) provided on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve gingival irrigation per quadrant (D4921).  You asked the Plan to pre-approve gingival irrigation per quadrant. You say that you have a diagnosis of acute gingivitis that is causing you to have a space between your jaw, teeth and molars causing your teeth and molars to be loose and falling out. Your dentist started treatment that provides more flexibility on your gums with less sensibility and more elasticity to your teeth and gums. You also say you need this treatment every three months to prevent the other natural teeth and molars from falling out. The Plan denied your request. The Plan says the requested service is not a covered benefit of Medicare or your 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation per quadrant (D4921).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the response and treatment, no transport, (A0998) provided on June 19, 2020.  You asked the Plan to pay for the ambulance service. You say that you were hyperventilating. You say that the paramedics determined that you had stabilized before the fire department arrived. You say that there was no reason for you to go to the emergency room. You also say that you do not feel obligated to pay this charge. The Plan denied your request. The Plan says there was no transport provided on the date of service in this case. The Plan also says that since no transport was provided, there is no payable 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 June 19, 2020. 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 response and treatment, no transport, (A0998) provided on June 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an x-ray (72110) provided on September 21, 2021.  You asked the Plan to waive the copayment for the x-ray. You say that the services should be covered as you have never had a copayment for them before. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for Outpatient diagnostic tests and therapeutic services and supplies.        You have been asked to pay a $35 copayment for the x-ray. X-rays 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 an x-ray (72110) provided on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for vision services (99205, 92235, 92020, 99250) provided on September 7, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for out-of-network vision care. You say that you got this provider's name from the Plan and the provider told you that they take your insurance. Then, two days before your appointment, you were told that they are no longer contracted with your plan. You say it was too late to get a new appointment elsewhere at that point, and you could not wait five months for another appointment. The Plan denied your request. The Plan says out-of-network care is only covered in certain limited circumstances. The services in this case were not urgent or emergent, nor were they pre-approved or referred by a Plan provider.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for vision services (99205, 92235, 92020, 99250) provided on September 7, 2021, by an out-of-network (OON) provider.   Your complaint about a potential last-minute participation status change and difficulty finding a timely appointment with an in-network provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.  You asked the Plan to pre-approve IRF care. You say that the enrollee requires the active and ongoing therapeutic intervention of multiple therapy disciplines. The Plan denied your request. The Plan says that the member's medical and therapy needs could be met in a skilled nursing unit.  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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Moh's surgery (17311) and the adjacent tissue transfer or rearrangement of the eyelids, nose, ears and/or lips (14060) rendered by the out-of-network (OON) provider on November 9, 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 Moh's surgery (17311) and the adjacent tissue transfer or rearrangement of the eyelids, nose, ears and/or lips (14060) rendered by the out-of-network (OON) provider on November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services provided on September 1, 2021.  You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says this provider has opted out of Medicare.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program. These services were provided by a physician who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for physician services provided on September 1, 2021.