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

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. You may see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. If you use a provider that has opted out of Medicare, you will not receive reimbursement. You can find this information on pages 65-67 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules 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. You can find this in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.3.2.1.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules 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. You can find this in the Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.3.2.1.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the additional periapical x-rays (D0230 x
2) provided on August 25, 2021.
You asked the Plan to pay the in network rate for the 2 additional periapical x-rays. You say that the closest in
network dentist is 2 to 3 hours away from the enrollee. You also say that an exception should be made. The
Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan also says that
the frequency limit has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and periapical x-ray is listed as
covered, the frequency limit has been exceeded. The record shows that the Plan paid for the initial periapical xray
that you received on the date of service in this case. Therefore, we decided that the Plan does not have to
pay the in network rate for the additional periapical x-rays (D0230 x 2) provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for injections (62320) provided September 27, 2021.  You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  The Plan must follow Medicare rules. Medicare rules say that 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. Insufficient clinical records were provided to support the code billed. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (62320) provided September 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance services and the inpatient hospital admission you had on November 15, 2020.
You asked the Plan to waive the copayments for the ambulance services and the inpatient hospital admission. You say that you were transferred from one hospital to another through no fault of your own, so you should not be responsible for these charges. The Plan denied your request. The Plan says these copayments were 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 $200 copayment for ambulance services and a $75 copayment per day for days 1-7 for inpatient hospital services. The inpatient copayment applies each time you are admitted. You have been asked to pay a $200 copayment for the ambulance services and a $75 copayment for the inpatient hospital admission. These copayments apply regardless of the reason for the 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 copayments for the ambulance services and the inpatient hospital admission you had on November 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for injections (62320) provided August 16, 2021.  You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.  The Plan must follow Medicare rules. Medicare rules say that 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. Insufficient clinical records were provided to support the code billed. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (62320) provided August 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments and coinsurance for a myocardial perfusion imaging (SPECT) study, a cardiovascular stress, and a technetium tc-99m dose provided on August 2, 2021. We decided that the Plan does not have to waive the copayments and coinsurance for a myocardial perfusion imaging (SPECT) study, a cardiovascular stress, and a technetium tc-99m dose provided on August 2, 2021. You have been asked to pay $317.20 for the SPECT study, stress test, and technetium dose. The SPECT study, stress test, and technetium dose fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments and coinsurance for a myocardial perfusion imaging (SPECT) study, a cardiovascular stress, and a technetium tc-99m dose provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided July 17, 2020.
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan denied your request. The Plan says the claim was not filed timely.
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 the office visit was not filed until August 20, 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 an office visit (99213) provided July 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spirometry test you had on April 1, 2021.

You asked the Plan to waive the copayment for the spirometry test. You say that this test was related to COVID-19, so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that all COVID-19-related cost sharing waivers are no longer in effect as of April 1, 2021.

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 non-radiological diagnostic services. 

You have been asked to pay a $20 copayment for the spirometry test. The spirometry test falls within the non-radiological diagnostic 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. Please note that the Plan's website explicitly states that if you receive COVID-19 treatment, you are responsible for any copay, coinsurance, or deductible. Therefore, we decided that the Plan does not have to waive the copayment for the spirometry test you had on April 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the contact lens fitting (92310) provided on October 15, 2021.  

You asked the Plan to pay for the contact lens fitting. You say that this was a follow-up visit and these services should be covered. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan.  

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.   

Though the Plan offers a vision 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 contact lens fitting (92310) provided on October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit you had on November 18, 2020.

You asked the Plan to waive the copayment for the specialist visit. You say that you were never informed about any copayments, and you cannot afford this bill. 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 specialist visits. 

You have been asked to pay a $20 copayment for the specialist 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 waive the copayment for the specialist visit you had on November 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) rendered by the out-of-network (OON) provider on August 27, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) rendered by the out-of-network (OON) provider on August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the physical therapy services you received on September 24, 2021.  

You asked the Plan to waive the copayment for the physical therapy services. You say that you don't believe you should have to separate copayments for these services.  You said that you had to go to this provider four different times for both hands.  You said that you do not understand why they couldn't do therapy on both hands at the same time. 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 each for physical, occupational, and speech therapy visits.   

You have been asked to pay a $25 copayment for the physical therapy services. This copayment applies to each visit, regardless of the reason for the 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 waive the copayment for the physical therapy services you received on September 24, 2021.   

Your complaint about not having therapy on both hands at the same time 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), and root canal (D3330) provided on July 21, 2021.

You asked the Plan to pay for the dental services. You say that since supplemental dental services are not covered by Medicare, dental services provided by a Medicare opt-out provider, will be considered out of network. You say that you have not reached our maximum allowance. You also say that the claim should be reconsidered. The Plan denied your request. The Plan says payment cannot be made for services rendered by a provider that has opted out of Medicare.

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, you signed a financial agreement accepting responsibility for services not covered. Additionally, the record shows that you were advised prior to receiving the services that coverage would not be available. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), and root canal (D3330) provided on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99202) rendered by the out-of-network (OON) provider on August 25, 2021.  

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99202) rendered by the out-of-network (OON) provider on August 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the abdomen you had on September 8, 2021.  

You asked the Plan to waive the copayment for the CT scan. You say that you were not informed of these charges. 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 $300 copayment for CT scans.   

You have been asked to pay a $300 copayment for the CT scan. 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 computed tomography (CT) scan of the abdomen you had on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) and the nasal endoscopy, diagnostic, unilateral or bilateral (31231) rendered by the out-of-network (OON) provider on October 6, 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 office visit (99204) and the nasal endoscopy, diagnostic, unilateral or bilateral (31231) rendered by the out-of-network (OON) provider on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunization administration (90471), the laboratory service (86580), and the federally qualified health center visit (G0467) rendered by the out-of-network (OON) provider on September 13, 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 immunization administration (90471), the laboratory service (86580), and the federally qualified health center visit (G0467) rendered by the out-of-network (OON) provider on
September 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on September 1, 2021.  

You asked the Plan to pay for the ambulance service. You say that the paramedics did not really do anything. You say that you did not call 911. You say that you were advised that you would not be billed because you were not transported to the hospital. The Plan denied your request. The Plan says there was no transport provided on the date of service in this case. The Plan also says that since no transport was provided, there is no payable service.  

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   

The ambulance company did not provide transport services on September 1, 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, no transport, (A0998) provided on September 1, 2021.