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

We decided that the Plan does not have to pay for the eye exam and glasses provided on April 2, 2021.

You asked the Plan to pay for the eye exam and glasses. You say that you were out of state when your glasses broke so you had an eye exam and obtained replacement glasses. You say that you did not know of any in-network provider. The Plan denied your request. The Plan says in-network providers were available.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are received from a network provider. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eye exam and glasses have not been met. Specifically, the services were received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the eye exam and glasses provided on April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on April 15, 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 claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied.
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the
Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to
pay for the initial hospital care rendered on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with a hand surgeon on 
July 12, 2021. 
 
You asked the Plan to waive the copayment for the hand surgery visit. You say that this visit was after your 
surgery, so the cost should be included. 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 $25 
copayment for visits with a specialist.

You have been asked to pay a $25 copayment for the hand surgery visit. Records show that you had surgery on 
March 23, 2021.  According to Medicare rules, the surgery you had has a 90-day global surgery period, 
meaning that follow-up visits you have during this period are included in the cost of the surgery.  The follow-
up visit you had on July 12, 2021, was after this 90-day period expired, so a separate copayment can apply. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the visit you had with a hand surgeon on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the joint aspiration procedure you had in a radiologist's office on January 8, 2021, the dermatology visit you had on January 12, 2021, the magnetic resonance imaging (MRI) of the lower extremity and the MRI of the lumbar spine you had on January 27, 2021, the office visits with a sports medicine specialist you had on February 12, 2021 and February 26, 2021, and the injection procedure you had at an outpatient hospital son February 15, 2021.
You asked the Plan to waive the cost sharing for the procedure in the radiologist's office, the dermatology visit, the two MRIs, the two office visits with a sports medicine specialist, and the outpatient hospital procedure. You say that you thought all of these services were covered in full because they were ordered by your primary care provider. The Plan denied your request. The Plan says you were charged these cost sharing amounts 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 $10 copayment for services with a specialist, a $100 copayment for each diagnostic radiology service, and a $275 copayment for services in an outpatient hospital facility. You have been asked to pay a $10 copayment for the procedure in the radiologist's office, the dermatology visit, and the two office visits with a sports medicine specialist. You have been asked to pay a $100 for each of the two MRIs you had. You have also been asked to pay a $275 copayment for the injection procedure that you had in an outpatient hospital facility. Each of the office visits were with specialists, so the $10 copayment per visit was applied appropriately. The MRIs are considered diagnostic radiology services, so those $100 copayments were charged correctly. Any procedure in an outpatient hospital facility applies a $275 copayment in accordance with your contract. These cost sharing amounts apply even if the services are ordered by your primary care provider. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the joint aspiration procedure you had in a radiologist's office on January 8, 2021, the dermatology visit you had on January 12, 2021, the magnetic resonance imaging (MRI) of the lower extremity and the MRI of the lumbar spine you had on January 27, 2021, the office visits with a sports medicine specialist you had on February 12, 2021 and February 26, 2021, and the injection procedure you had at an outpatient hospital son February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the podiatry visit you had on June 24, 
2021. 
 
You asked the Plan to reduce the copayment for the podiatry visit. You say that you believe your copayment is 
only $15 for podiatry services. The Plan denied your request. The Plan says you were charged this copayment 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for visits with a podiatrist.  
 
You have been asked to pay a $25 copayment for the podiatry visit. 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 podiatry visit you had on June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 2) and take-home 
medication (D9610) provided on July 28, 2021. 
 
You asked the Plan to pay for gingival irrigation and take-home medication. You say that you were advised the 
services would be covered. The Plan denied your request. The Plan says gingival irrigation is not a covered 
service. The Plan also says that take-home medication is not listed as a covered service either. 
 
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 gingival irrigation and take-home 
medication are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the gingival irrigation (D4921 x 2) and take-home medication (D9610) provided on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee with June 14, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 out of network physician services provided to the enrollee with June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for infusion therapy services and Iron Dextran drug you received at an outpatient hospital facility on May 15, 2021.

You asked the Plan to waive the cost sharing for the infusion therapy services and the Iron Dextran drug. You say that these were continuing services from an inpatient stay, so there should be no extra copayment. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that for the infusion therapy services, the allowed amount for this service ($205.49) is less than your copayment obligation, so 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 $310 copayment for medical services at an outpatient hospital facility and 20% coinsurance for Medicare Part B drugs.

You have been asked to pay a $310 copayment for the infusion therapy services and 20% coinsurance for the Iron Dextran drug. The infusion therapy services fall within the medical services at an outpatient hospital facility benefit category and the Iron Dextran drug falls in the Medicare Part B drugs benefit category. Although they may have been related to a previous hospitalization, these services occurred after you were discharged. 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 cost sharing for infusion therapy services and Iron Dextran drug you received at an outpatient hospital facility on May 15, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit (99284) provided on May 26, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $90 copayment for each emergency room visit. 

You have been asked to pay a $90 copayment for the emergency room visit provided. This means that you have been asked to pay the correct amount based on your contract with the Plan.

This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit (99284) provided on May 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the acute inpatient rehabilitation facility care provided from March 31, 2021, through April 8, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment per day, for days 1-6 only, for each Medicare-covered in-network inpatient hospital care stay.
The enrollee has been asked to pay $1,350 ($225 copayment x 6 days) for the Medicare-covered in-network inpatient rehabilitation facility care stay provided. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the acute inpatient rehabilitation facility care provided from March 31, 2021, through April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a maxillary partial denture (D5225) and a panoramic radiographic image (D0330) provided on June 1, 2021.

You asked the Plan to pay for a maxillary partial denture and a panoramic x-ray. You say that dentures were needed to replace extracted teeth due to gum inflammation and gingivitis from a serious periodontal disease. You also say you had gaps between your teeth which caused teeth to shift. You were not aware of the additional charge. The Plan denied your request. The Plan says you are responsible for the cost of non-covered 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 you had a partial denture provided to you on July 14, 2020, and the EOC confirms you are allowed a partial denture once every five plan years. The records also show that you had a panoramic x-ray provided to you on July 24, 2019, and the EOC confirms that you are allowed a panoramic x-ray once every three plan years. Therefore, you have exhausted your maximum allowed benefit. Based on this information, we decided that the Plan's rules for coverage of a maxillary partial denture and a panoramic x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a maxillary partial denture (D5225) and a panoramic radiographic image (D0330) provided on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services rendered on April 8, 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 procedure code 99053 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified.  
 
We looked at the file and Medicare rules. Billed procedure code 99053 (service(s) provided between 10:00 PM 
and 8:00 AM at 24-hour facility, in addition to basic service) has a status indicator of B and no separate 
Medicare payment. Therefore, we decided that the Plan does not have to pay for the medical services rendered 
on April 8, 2021.
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 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 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. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or 
occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin injections provided on July 23, 2020.

You asked the Plan to pay for the vitamin injections. The Plan denied your request. The Plan says that the
nutria-pharmaceutical blend/mix was administered; therefore, each component of the blend cannot be billed
separately.

The Plan must follow Medicare rules. Medicare rules say that claims for compounded drugs shall be submitted
using a compounded drug, not otherwise classified (NOC) code.

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 multiple drug codes reported on this
claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be
billed using the not otherwise classified code J7999. As this compounded drug was not billed properly,
payment cannot be made. Therefore, we decided that the Plan does not have to pay for the vitamin injections
provided on July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for bitewing x-rays (D0274) and prophylaxis (D1110) provided on May 25, 2021, by an out-of-network (OON) provider.
You asked the Plan to reimburse you for bitewing x-rays and prophylaxis. You say that you are requesting a full reimbursement as well as full and complete reason for the cost share and a schedule of what procedures are allowed and the cost share of each item. The Plan denied your request. The Plan says since your dentist is OON, the Plan pays up to a certain amount and you are responsible for all the fees in excess of what the Plan pays.
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 bitewing x-rays and prophylaxis when the services are received from an in-network provider.
We looked at the file and Medicare rules. The EOC confirms that if you choose to see an OON dentist you might be billed for charges above what the plan pays, even for services listed as a $0 copayment. Based on this information, we decided that the Plan's rules for coverage of bitewing x-rays and prophylaxis have not been met. Therefore, we decided that the Plan does not have to reimburse you for bitewing x-rays (D0274) and prophylaxis (D1110) provided on May 25, 2021, by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services for a knee arthroplasty (27447)
provided on February 18, 2021.
You asked the Plan to pay for surgical assistant services for a knee arthroplasty. You say that the requested
services were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for
payment have not been met.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services for a knee
arthroplasty (27447) provided on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and personal protective equipment (PPE) (D1999) provided on June 22, 2021.

You asked the Plan to pay for a limited oral evaluation and PPE. You say that the provider evaluated your infected crown and took x-rays. The provider then told you to go somewhere else to have it fixed. You also say that you would like this visit covered and you want to be able to have covered x-rays at your next appointment. The Plan denied your request. The Plan says these are not covered services under your preventive or comprehensive dental benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and personal protective equipment (PPE) (D1999) provided on June 22, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 10,
2021.
You asked the Plan to pay for the subsequent nursing facility care. You say that the service provided was
medically necessary and patient care was provided as an urgent request to avoid wound complications. 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 enrollee's terminal condition.
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 the subsequent nursing facility care provided on June 10,
2021.