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

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E2031), to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a semi-electric hospital bed. You say that the item is medically necessary. The Plan denied your request. The Plan says there are network providers available to provide this item.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E2031), to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series
x-ray (D0210), scaling and root planning (D4342 x 2), gingival irrigation (D4921), and take-home drugs
(D9630) provided from September 29, 2021, to September 30, 2021.
You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that
this dental office was in this case was in network. You say that after you received the services, you were
advised the physician there is temporary. You also say that you were unaware of the requirement for physicians
at the facility. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan
also says that dental services received out of network 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, dental services received out of network
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for
the comprehensive oral evaluation (D0150), complete series x-ray (D0210), scaling and root planning (D4342
x 2), gingival irrigation (D4921), and take-home drugs (D9630) provided from September 29, 2021, to
September 30, 2021.
Your complaint about being misled by a plan representative 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation services provided on May 28, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that the provider instructed you to use the ambulance and your wife was not allowed to take you. 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 a $325 copayment per trip for ambulance services.

You have been asked to pay $249.22, which is less than the $325 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services 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 ambulance transportation services provided on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87070, 87077, 87186) rendered by the out-of-network (OON) provider on November 22, 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 laboratory services (87070, 87077, 87186) rendered by the out-of-network (OON) provider on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture (D0364) provided on July 6, 2021.

You asked the Plan to pay for the dental imaging. You say that this service was medically necessary. The Plan denied your request. The Plan says this service is not covered by your dental 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 the cone beam CT capture (D0364) provided on July 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a pneumatic walking boot provided on
August 6, 2021.
You asked the Plan to waive the coinsurance for the walking boot. You say that you did not receive the boot
and you should not be getting billed for it. The Plan denied your request. The Plan says the correct coinsurance
was 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 20%
coinsurance for durable medical equipment (DME) and supplies, including walking boots.
The file shows that you had signed for and were fitted with the walking boot. Therefore, you have been asked
to pay $51.98, which is 20% of the allowed amount for the walking boot ($259.89 allowed amount x 20%
coinsurance = $51.98). The walking boot 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 pneumatic walking boot
provided on August 6, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for transplant related lodging, meals and transportation provided from
August 23, 2021, through August 25, 2021.
You asked the Plan to pay for transplant related lodging, meals and transportation. You say that that you live
142 miles from your doctor and this visit was a follow up to your transplant. The Plan denied your request. The
Plan says that the services were not transplant related.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the Plan has not provided us with medical records from this follow
up visit, the Plan has not provided us with the rule in the Evidence of Coverage to support the denial.
Additionally, the codes billed are transplant related codes. Therefore, we decided that the Plan has to pay for
transplant related lodging, meals and transportation provided from August 23, 2021, through August 25, 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for two admissions of inpatient hospital care
provided from March 5, 2021, to April 17, 2021.
You asked the Plan to waive the copayment for the admissions of inpatient hospital care. You say that the
services should be covered. 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 $325
copayment for Inpatient hospital care.
You have been asked to pay a $325 copayment each for two admissions of inpatient hospital care. 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 two admissions of inpatient hospital care provided from March 5,
2021, to April 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), resin-based composite - one surface, posterior (D2391), and resin-based composite - two surfaces, posterior (D2392) provided September 27, 2021.

You asked the Plan to pay for the bitewing x-rays, periodic oral exam, dental cleaning, and fillings. You say that you disagree with the denial. The Plan denied your request. The Plan says you have exhausted your dental allowance for 2021.

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 bitewing x-rays, periodic oral exam, dental cleaning, and fillings up to an annual maximum of $1,500.

We looked at the file and Medicare rules. The Plan provided documentation showing that the Plan has applied the full $1,500 annual maximum to your dental claims in 2021. Based on this information, we decided that your dental benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), resin-based composite - one surface, posterior (D2391), and resin-based composite - two surfaces, posterior (D2392) provided September 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis tablet.
You asked the Plan to pre-approve Eliquis. You say that the requested drug is medically necessary. The Plan
denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the
requested drug is not covered under Medicare 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 pre-approve Eliquis tablet.
Benefits for Eliquis 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on August 20,
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 you have exceeded the allowable benefit for
this service.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once
every 12 months.

Based upon the review of the file, an AWV was provided less than 12 months prior to the visit at issue in this
case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit (G0439) provided
on August 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the scaling and root planing (D4341) for the upper right and lower right quadrants provided on September 30, 2021.  You asked the Plan to pay an additional amount for the dental services. You say that the services were preventive. You say that you used your benefit for a necessary filling and scaling on the other side of your mouth. You say that you want to keep your mouth healthy. You also say these services should be covered. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000. The Plan also says that the maximum benefit has been exhausted in processing this claim.  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 scaling and root planing is listed as covered, the annual maximum benefit has been exhausted.  Date of Service Plan Paid Your Responsibility 9/2/2021 $287 $0 9/9/2021 $555 $0 9/30/2021 $158 $69 TOTAL: $1,000 $69  The record shows that the Plan paid the remaining amount of your maximum benefit, or $158, towards the scaling and root planing for the upper right quadrant, thus exhausting the benefit. Additionally, the Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for the scaling and root planing (D4341) for the upper right and lower right quadrants provided on September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the knee orthosis (L1851) suspension sleeve (L2397) provided September 28, 2021.  You asked the Plan to pay for the orthoses. You say that the claim denied in error for no authorization. However, this claim is for an out of network DME purchase. The enrollee is using their out of network DME benefits. The Plan denied your request. The Plan says precertification/authorization/notification/pre-treatment absent. The records do not support the need or justification for the braces.  The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.  We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1851) suspension sleeve (L2397) provided September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) visit for an ear wax removal procedure provided on October 4, 2021.  You asked the Plan to waive the copayment for the PCP visit. You say that you did not have the procedure done on that day. 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 a $10 copayment for each primary care physician (PCP) visit.   The record shows that visit notes indicate the procedure was performed. Therefore, you have been asked to pay a $10 copayment for the PCP visit. The PCP visit falls 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 copayment for a primary care physician (PCP) visit for an ear wax removal procedure provided on October 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic x-ray provided by on July 28,
2021.
You asked the Plan to waive the copayment for a diagnostic x-ray. You say that this test should have never
been done by your cardiologist. The Plan denied your request. The Plan says the provider billed for the services
and the proper copayment was 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 $85
copayment for Basic Radiological Services at an Outpatient Hospital. The total amount allowed was $80.19
which is less than the copayment amount of $85. Therefore, $80.19 was charged as the copayment.
You have been asked to pay a $80.19 copayment for a diagnostic x-ray. A diagnostic x-ray falls 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 a diagnostic x-ray provided by on July 28, 2021.
Your complaint about unnecessary test by this 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal cord injection (62320) provided on September 27, 2021.

You asked the Plan to pay for the spinal cord injection (62320). You say that the procedure billed is for subarachnoid injection therefore the policy of interlaminar epidural injections is not applicable. You say that subarachnoid opioids are very effective for decreasing pain and the service should be paid. The Plan denied your request. The Plan says the provider has not submitted any clinical records to support the medical necessity of the service.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. The rules also say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the spinal cord injection (62320) have not been met. Specifically, medical records were not submitted to determine if Medicare coverage criteria have not been met. Therefore, we decided that the Plan does not have to pay for the spinal cord injection (62320) provided on September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and pulp vitality test (D0460) provided on October 12, 2021.

You asked the Plan to pay for the dental services. You say that the limited oral evaluation helped to determine that you did not need a root canal. You also say your plan would save money with the pulp vitality test. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan says that the frequency limit has been exceeded. The Plan also says that pulp vitality test is not listed as a covered 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 and limited oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on July 20, 2021. Additionally, the pulp vitality test is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and pulp vitality test (D0460) provided on October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx testing provided on September 7, 2021.

You asked the Plan to pay for the testing services. You say that the test predicts the likelihood that prostate cancer will be found by a biopsy. The Plan denied your request. The Plan says screening services without a valid diagnosis are not a benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

We looked at the file and the rules. The testing was performed as a screening to identify those at risk for aggressive disease. There are insufficient records to show that the testing was ordered due to testing that was significantly different than previous. The test at issue in this appeal was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing provided on September 7, 2021.