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

 We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) or pay more for the four periodontal scalings and root planings (D4341 x4) provided on April 12, 2021.  You asked the Plan to pay for the comprehensive periodontal evaluation and to pay more for the scalings and planings. You say that you were told these services would be completely covered. The Plan denied your request. The Plan says benefits for the comprehensive periodontal evaluation have been satisfied and the frequency limitation has been exceeded, and the scalings and planings were processed according to the Plan's negotiated rate. The Plan also says that no calls from yourself nor the provider were made to the Plan prior to the 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, periodontal exam and comprehensive oral evaluation share a frequency limitation of one procedure code every three years. The record shows that you received a comprehensive oral evaluation on April 8, 2021 and your periodontal exam and comprehensive oral evaluation benefits have been exhausted. The contract also clearly states that you are responsible for a 70% coinsurance for each scaling and root planing provided in-network. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) or pay more for the four periodontal scalings and root planings (D4341 x4) provided on April 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on November 20, 2019.

You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says the claim was filed past the allowed 12-month timeframe.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for ambulance services was not filed until July 29, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for ambulance services provided on November 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the metered dose inhaler drug provided on April 28, 2021.  You asked the Plan to pay for the metered dose inhaler drug. You say that the documentation supports the medical necessity for the rendered service. The Plan denied your request. The Plan says payment for this service would be included in the facility payment.  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, the CPT Code Manual definition of code J3535 is drug administered through a metered dose inhaler.    We find that CPT code J3535 is not supported in the medical record. Specifically, this code is not paid by Medicare when submitted on outpatient claims. Based on this information, we decided that Medicare rules for coverage of the metered dose inhaler drug have not been met. Therefore, we decided that the Plan does not have to pay for the metered dose inhaler drug provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the determination of refractive state (92015) provided June 28, 2021.  You asked the Plan to pay for the eye refraction. You say that you believe the service should be covered. The Plan denied your request. The Plan says the service was not provided by a specified dental provider, and therefore are not covered.  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 rendered by a specified vision provider.  We looked at the file and the Plan's rules. In this case the service was not provided by a specified vision vendor. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) provided June 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that you have foot pain. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve psychotherapy services to be provided by a provider not enrolled in the Medicare program.  You asked the Plan to pre-approve psychotherapy services. You say that the provider at issue is the right person to address your current difficulties. The Plan denied your request. The Plan says rules for coverage have not been met.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pre-approve psychotherapy services to be provided by a provider not enrolled in the Medicare program.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray you received from a podiatrist on July 6, 2021.

You asked the Plan to waive the copayment for the x-ray. You say that you do not believe this x-ray was necessary. 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 $20 copayment for x-rays.

You have been asked to pay a $20 copayment for the x-ray. This copayment applies regardless of the reason for the x-ray. 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 x-ray you received from a podiatrist on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the general anesthesia (D9222 and D9223).  You asked the Plan to pre-approve the general anesthesia. You say that the service should be covered. The Plan denied your request. The Plan says the service is 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. Specifically, the requested service is not listed in the Plan's benefit chart. This means the service is not covered. Therefore, we decided that the Plan does not have to pre-approve the general anesthesia (D9222 and D9223).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the angiography services provided on October 15, 2020.

You asked the Plan to pay for the services provided. You say that the modifier was correctly applied. The Plan
denied your request. The Plan says the code is not supported in the documentation.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the
service billed with the modifier indicates a distinct procedural service.

We looked at the file and the rules. The medical records do not show that the service billed with the -59
modifier is a distinct procedural service. Based on this information, we decided that Medicare rules for
coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not
have to pay for the angiography services provided on October 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the breast implant services provided on May 5, 2021.  You asked the Plan to pay for the services provided. You say that medical records were provided. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT codes 19328, 19340, 19370, 19371, and 19380 is 1. The MAI value for these codes is 2. You billed 2 units for each code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the breast implant services provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided August 3, 2021.

You asked the Plan to pay for the comprehensive oral exam and complete series of x-rays. You say that you were dissatisfied with this dentist, do not understand the cost of the high cost for the visit and would like to go to a new dentist. The Plan denied your request. The Plan says you have exceeded the frequency limits for these 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. The Plan covers a comprehensive oral exam once every three years and a complete series of x-rays once every five years. 

We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam and complete series of x-rays were previously covered on January 10, 2020. Based on this information, we decided that the Plan's frequency limit for these services has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided August 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion provided on April 13, 2021 and April 16, 2021.  You asked the Plan to pay for the home infusions. You say that the nursing notes should be reviewed and reconsidered for payment. The Plan denied your request. The Plan says the code is not valid for Medicare billing purposes.  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, the CPT Code Manual definition of code 99601 is home infusion/specialty drug administration, per visit (up to 2 hours).    We find that CPT code 99601 is not supported in the medical record. Specifically, CPT code 99601 has a status indicator of I. This means that CPT code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusions have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion provided on April 13, 2021 and April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the root canal therapy (D3347).  You asked the Plan to pre-approve the root canal therapy. You say that the service should be covered. The Plan denied your request. The Plan says this is not 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, the requested items or services are not among those covered under this benefit. Specifically, the requested service is not listed in the Plan's benefit chart. This means that the service is not covered. Therefore, we decided that the Plan does not have to pre-approve the root canal therapy (D3347).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye exam (92004), progressive lenses (V2781), deluxe frames (V2025) and an extended ophthalmoscopy w/retinal drawing (92225) provided on June 17, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an eye exam, progressive lenses, deluxe frames, and an extended ophthalmoscopy w/retinal drawing. You say that you do not agree with the denial of this claim. The Plan denied your request. The Plan says you must use a specified provider for routine coverage including routine exam, retinal imaging, and eyewear allowance.  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 provider who participates in the Plan's specified vision network.  We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. Based on this information, we decided that the Plan's rules for coverage of an eye exam, progressive lenses, deluxe frames and an extended ophthalmoscopy w/retinal drawing have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam (92004), progressive lenses (V2781), deluxe frames (V2025) and an extended ophthalmoscopy w/retinal drawing (92225) provided on June 17, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the retreatment of previous root canal (D3348), endodontic therapy (D3320), apicoectomy (D3245), retrograde filling (D3430), and a bone replacement graft (D97952).  You asked the Plan to pre-approve the retreatment of previous root canal, endodontic therapy, apicoectomy, retrograde filling, and a bone replacement graft. You say that the services are medically necessary. The Plan denied your request. The Plan says the 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. Specifically, the requested services are not listed in the Plan's benefit chart. This means the services are not covered. Therefore, we decided that the Plan does not have to pre-approve the retreatment of previous root canal (D3348), endodontic therapy (D3320), apicoectomy (D3245), retrograde filling (D3430), and a bone replacement graft (D97952).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the arthrocentesis procedure, the x-ray, and the Kenalog injection you received in a specialist's office on June 15, 2021.  You asked the Plan to waive the cost sharing for the arthrocentesis procedure, the x-ray, and the Kenalog injection. You say that this is not a surgery and this copayment should not apply. The Plan denied your request. The Plan says this cost sharing was assessed correctly.  The Plan granted you a one-time exception before, but that doesn't mean that this cost sharing was incorrect.  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 surgery services in a specialist's office, a $15 copayment for basic radiological services in a doctor's office, and 20% coinsurance for Medicare Part B drugs.  You have been asked to pay a $25 copayment for the arthrocentesis procedure, a $15 copayment for the x-ray, and 20% coinsurance for the Kenalog injection. Medicare considers the arthrocentesis procedure you had to be a surgical procedure.  The x-ray is a basic radiological service, and the Kenalog injection is a Part B drug.  This means that you have been asked to pay the correct amounts 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 arthrocentesis procedure, the x-ray, and the Kenalog injection you received in a specialist's office on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on April 10, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the nursing facility care. You say that the doctor has no prior knowledge of insurance and/or authorization and only sees patients at the time of service and is referred to patients by the nursing home facility for pain management care. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 subsequent nursing facility care (99309) provided on April 10, 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 rendered from July 21, 2021, to July 22, 2021.

You asked the Plan to waive the copayment for inpatient hospital services. You say that you are filing this appeal due to financial hardship. The Plan denied your request. The Plan says you were charged the correct copayment 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 $320 copayment per day for days 1-5 for inpatient hospital care. 

You have been asked to pay a $320 copayment inpatient hospital services. 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 rendered from July 21, 2021, to July 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you received on January 30, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that this was COVID-19-related and this is too much money for you to pay. The Plan denied your request. The Plan says this copayment was charged 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 $440 copayment for ambulance services.   According to the Plan's website, the Plan is only waiving cost sharing for diagnostic visits and lab tests related to COVID-19.  The Plan is not waiving cost sharing for any other services at this time. You have been asked to pay a $440 copayment for the ambulance services. 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 services you received on January 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral exam (D0140), and bitewing x-rays (D0270) provided on July 20, 2021.  You asked the Plan to pay for the dental services. You say that you understood that this provider was part of your dental network and these services would be covered. The Plan denied your request. The Plan says they have agreed to re-process this claim as in-network care. The filling and the intraoral x-ray are covered; however, you have exceeded your benefit limitation for bitewing x-rays during the current calendar year, and the limited oral exam is not a covered service. Therefore, the bitewing x-rays and limited exam remain 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 periodic, periodontal and comprehensive oral exams. The Plan can cover one set of bitewing x-rays per calendar year.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit or are requested in a frequency that exceeds what is covered by this benefit. The limited oral exam is not listed as a covered service, and the provided documentation shows that you had a previous set of bitewing x-rays provided on May 17, 2021, which was covered by the Plan at that time. Therefore, we decided that the Plan does not have to pay for the limited oral exam (D0140), and bitewing x-rays (D0270) provided on July 20, 2021.