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

 We decided that the Plan does not have to pay for foot orthotics provided on February 3, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the foot orthotics. You say that you did not know that you needed to obtain services from network providers. The Plan denied your request. The Plan says you did not obtain the services from a network 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 foot orthotics provided on February 3, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from August 6, 2021, to August 7, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that the claim is not accurate.  You said that you did not receive any of the therapies listed on the claim. 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 $325 copayment per day for days 1-6 for inpatient hospital care.   Records show that you were in the hospital for one day. You have been asked to pay a $325 copayment for the inpatient hospital services. This copayment applies regardless of the extent of services you receive while you are an inpatient. 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 inpatient hospital services provided from August 6, 2021, to August 7, 2021.   Your complaint about the bill accurately listing the services received 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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intravenous infusion provided on January 29, 2021.  You asked the Plan to pay for the intravenous infusion. You say that the patient sought medical care with a chief complaint of chronic pain and the services provided were medically necessary. You say that the claim was processed incorrectly which resulted in a reimbursement rate below what the terms of the plan, and higher payment should be made. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code edit.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 96365 is a column II code to column I code 99350. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the intravenous infusion provided on January 29, 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 June 24, 2021.  You asked the Plan to pay for the comprehensive exam. You say that you were told you had one more oral evaluation this year that would be covered and feel this service was denied in error. The Plan denied your request. The Plan says you had a previous comprehensive oral evaluation in January 2019, which was covered by the Plan at that time. This type of exam is only covered once every three years. Therefore, payment for the exam on the date in question is denied.  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 comprehensive oral evaluation or periodontal exam every three calendar years.   Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive exam is requested in a frequency that exceeds what is covered under this benefit. Documentation shows that you had a previous comprehensive oral exam less than three years before the date in question. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the x-ray of the abdomen you had at an outpatient hospital facility on August 12, 2021.

You asked the Plan to reduce the copayment for the x-ray. You say that you believe you should only have to pay a $40 copayment for this service. You said that this was done at a standalone x-ray facility that is affiliated with the hospital. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($74.59) is less than your copayment obligation, you are responsible for the full allowed 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 $100 copayment for basic radiology services at an outpatient hospital.

You have been asked to pay a $100 copayment for the x-ray. The facility that performed this service is considered part of an outpatient hospital facility. That is why the x-ray falls within the basic radiology services at 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 reduce the copayment for the x-ray of the abdomen you had at an outpatient hospital facility on August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the crown for tooth # 3.  You asked the Plan to pre-approve the crown for tooth # 3. The Plan denied your request. The Plan says the tooth can be fixed with fillings.  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 crown for tooth # 3 when the services are medically necessary and reasonable.      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 the crown for tooth # 3. Our reviewer says that there is no necessity to place a crown on tooth # 3. Our physician reviewer found that there is an existing two surface restoration and no damaged cusps. There has been no showing of any other damage or fracture to tooth # 3. Our reviewer says that in this instance the tooth in question has substantial remaining structure and would be able to be restored with a conventional restoration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown for tooth #3 have not been met. Therefore, we decided that the Plan does not have to pre-approve the crown for tooth # 3.
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) provided February 2, 2021.  You asked the Plan to pay for the additional intraoral x-ray. You say that you feel the Plan should cover the service. 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 intraoral or bitewing x-rays per calendar year.   We looked at the file and Medicare rules. The Plan provided documentation showing that one intraoral x-ray and one set of bitewing x-rays were covered on February 2, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the additional intraoral x-ray has been exceeded. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image (D0230) provided February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep comfort bed (E1399).

You asked the Plan to pre-approve the sleep comfort bed. You say that the bed is required due to how bad the enrollee's back is. The Plan denied your request. The Plan says the requested item or service is not a covered benefit because it does not serve a medical purpose, is not reasonable and necessary for treatment of illness or injury and it is for comfort and convenience.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a sleep comfort bed (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a complete maxillary denture (D5110) provided by a participating provider on July 26, 2021

You asked the Plan to waive the coinsurance for a complete maxillary denture. You say that you were told that this would be covered 100%. 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 - supplemental/endodontics. 

You have been asked to pay a 70% coinsurance of the allowed amount for a complete maxillary denture. The total allowed amount is $724. The total amount you are being asked to pay is $506.80 ($724 x 70% = $506.80).

The correct coinsurance has been applied to the dentures that were provided. A complete maxillary denture falls within the dental services - supplemental/endodontics 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 complete maxillary denture (D5110) provided by a participating provider on July 26, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the false tooth (D6240) and white glass cap (D6750).  You asked the Plan to pre-approve the false tooth and white glass cap. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.  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 false tooth and white glass cap when the services are medically necessary and reasonable.   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 the false tooth and white glass cap. Our reviewer says that the service is not medically necessary. Our physician reviewer found the tooth has been missing for over three years according to the supplied x-rays and the teeth in the arch appear to be stable and not shifting. As there are missing teeth in the opposing side of the arch as well, replacements could also consider removable partial dentures, implants, or no replacements at all. In this instance there are no anterior teeth missing or being replaced on the requested bridge. The pontic tooth would be #13, a posterior tooth. There is no documented neurological or physical disorders that preclude the use of a removable appliance.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the false tooth and white glass cap have not been met. Therefore, we decided that the Plan does not have to pre-approve the false tooth (D6240) and white glass cap (D6750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) and deep sedation/general anesthesia - first 15 minutes (D9222) provided June 23, 2021.  You asked the Plan to pay for the tooth extraction and anesthesia. You say that you would like this service covered. The Plan denied your request. The Plan says this service isn't covered because you got the service from a provider who chose not to receive Medicare funds.  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 tooth extraction and anesthesia when the services are provided by a licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare.   We looked at this physician's review, the file, and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the tooth extraction and anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) and deep sedation/general anesthesia - first 15 minutes (D9222) provided June 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on May 24, 2021.  You asked the Plan to pay for the ambulance response without transport. You say that these services were medically necessary, even without transportation. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. Without transport, 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 May 24, 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 without transport (A0998) provided on May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a cone beam computed tomography (CT) capture and interpretation (D0364) and a panoramic radiographic image (D0330) provided on June 1, 2021.  You asked the Plan to pay for a limited oral evaluation, a cone beam CT capture, and a panoramic radiographic image. You say that you were in pain and needed immediate remedy/treatment. The Plan denied your request. The Plan says you received the maximum reimbursement allowance for non-Medicare covered dental services.  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. The records show that the provider is on the Medicare opt-out list. The records also show the total amount billed on this claim was $2,300. The Plan paid the maximum allowed amount of $1,250 due to misinformation provided to the provider by the Plan prior to services being rendered. The remaining balance of $1,050 is your responsibility as the maximum allowed amount has been paid. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, a cone beam CT capture and a panoramic radiographic image have not been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), a cone beam computed tomography (CT) capture and interpretation (D0364) and a panoramic radiographic image (D0330) provided on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), prophylaxis (D1110), and endodontic therapy (D3330) provided from March 23, 2021, to May 6, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, prophylaxis, and endodontic therapy. You say that you were reimbursed for a small claim in 2020, and no one advised you that this provider was no longer a covered network provider. You also say that these services were absolutely necessary. The Plan denied your request. The Plan says you received these services from a provider who chose not to receive Medicare funds. The Plan also says that the treating provider opted out of Medicare effective March 28, 2016, to March 28, 2022.

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 periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), prophylaxis (D1110), and endodontic therapy (D3330) provided from March 23, 2021, to May 6, 2021 by a Medicare opt out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit (99214) for a diagnostic eye exam, including imaging of the retina (92134) and the determination of whether prescription eyewear is needed (92015) provided on July 22, 2021.  You asked the Plan to waive the copayment for a diagnostic eye exam. You say that you believe the annual eye exam benefit, with a $0 copayment, should apply. You say you did not have to pay anything for annual exams in the past and would like the claim reduced to $0. You also say you spoke to a Plan customer support rep on August 18, 2021 and were advised the expenses should have been covered as an annual eye exam and to submit a formal appeal. The Plan denied your request. The Plan says the claim information submitted by the provider indicates the eye exam was related to a medical condition.   The Plan states the claim was billed with the following diagnoses: puckering of macula, left eye; vitreous degeneration, bilateral; age-related nuclear cataract, bilateral; and presbyopia. The Plan says the cost-share was applied correctly, in accordance with your 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 a $40 copayment for Vision Care.   You have been asked to pay a $40 copayment for a diagnostic eye exam. Diagnostic eye exams fall within the Vision Care benefit category. Due to your exam having a diagnostic element in relation to a medical condition, an additional copayment exceeding that of an annual exam applies. 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 office visit (99214) for a diagnostic eye exam, including imaging of the retina (92134) and the determination of whether prescription eyewear is needed (92015) provided on July 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayments for wound debridement services you received at an outpatient hospital facility from January 8, 2021, to April 2, 2021.  You asked the Plan to reduce the copayments for the wound debridement services. You say that these visits were supposed to be office visits with just a $25 copayment.  You said that you had a burn that did not require surgery.  You stated that you were never advised that this would be considered an outpatient procedure and if you had known, you would not have gone as often. The Plan denied your request. The Plan says you were charged these copayments correctly.  The Plan says that for two of the dates of service (March 5, 2021, and April 2, 2021), the allowed amount for these services ($111.09) is less than your copayment obligation, so you are responsible for the full allowed amount for those dates.  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 $250 copayment per visit for outpatient surgery in an outpatient hospital facility.   You have been asked to pay a $250 copayment per visit for the wound debridement services. Wound debridement is considered a surgical service.  In addition, these services occurred in an outpatient hospital facility. That is why the wound debridement services fall within the outpatient surgery in an outpatient hospital facility 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 reduce the copayments for wound debridement services you received at an outpatient hospital facility from January 8, 2021, to April 2, 2021.